National Implementation of TeamSTEPPS Program Webinar 11:
Using Simulation for Recurrency TeamSTEPPS Training

Moderator: Alex Alonso
June 17, 2009
11:00 am CT

Operator: Ladies and gentlemen, thank you for standing by and welcome to the TeamSTEPPS National Implementation Program Webinar 11: Improving Individual and Team Performance: TeamSTEPPS™ and In situ™ Simulation.

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 presentation, if you need to reach an operator, please press the star 0.

As a reminder, this conference is being recorded Wednesday, June 17th, 2009. I would now like to turn the conference over to Alex Alonso. Please go ahead, sir.

Alex Alonso: Thank you, operator.

Hi, I’d like to welcome everyone to the 11th webinar in the series of the National Implementation of TeamSTEPPS Program. Today, we’re joined by Stan Davis and Kristi Miller of Fairview Health Services who are going to be talking to us about using TeamSTEPPS and simulation to drive home the messages and refine the tools from the TeamSTEPPS program. As you all know, we are winding down our series of webinars, so I want provide you with a few reminders here.

First, we ask that you consider others while participating in this webinar. We ask that you please mute your phone to reduce the background noise, although note that the operator will be able to mute all lines. Please 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.

Cori, at this time, I’d like to let you give you some background on the Live Meeting software.

Cori White: Hi, most people today are connected through LiveMeeting, we know that there are a few of you that are not, and we will get to that in a minute.

If you are connected through LiveMeeting, the most important thing for you to know today is how to ask questions. We do have you defaulted to a listen-only mode, so it is important to know how to ask a question in live meeting. This also allows you to ask your question when you think of it, so you don’t have to remember it for later.

At the top of your live meeting window there should be a menu option that says Q&A. If you click on that, there should be a box that opens that has an area for you type your text in and ask your question.

We ask that you do type in the text of your question rather than just using the little hand icon. If you only use the hand icon, we won’t know what your question is.

So you can ask you question whenever you have it, and if it’s something we think needs to be addressed immediately or is something that can be addressed individually we will do that through live meeting. Otherwise have a number of questions slides built into the presentation, where we will stop and take care of all of your questions at that point.

The most frequent question that we receive that is not content related is asking about slides. If you are connected through live meeting today there is a place where you can download PDF copies of the slides, both in single slide format and in three-slide-per-page format. That would be at the top right hand corner of your LiveMeeting window. There is a little icon that looks like three pieces of paper. That will allow you to download the handouts.

Also on the top right hand part of your screen is a pull down that says “feedback” with a little colored square next to it. That square defaults to green which means that you’re okay. If you go in and change that you’ll see that there are options like you can’t here or we need to slow down. We will be monitoring that on and off throughout the call, so you can alert us to issues in that way.

The other item related to that is: please don’t use the question square, which is purple, because again, we won’t know what your question is. If you have a question, please enter it through the Q&A tab at the top of your screen.

For those of you on the phone, if you have not already emailed to ask for slides and you would like them, please do. You can email temasteppswebinars@air.org. That’s temasteppswebinars@air.org, and I’ll make sure that you get handouts.

If you’d prefer to ask your question in person rather than through Live Meeting, or if you’re not connected through LiveMeeting, then you will be able to queue up for questions on the phone as well. Operator, would you tell people please how to ask a question?

Operator: Sure thing ma’am. Ladies and gentlemen, to register for a question, please press the 1 followed by the 4 on your telephone. You will hear a three tone prompt to acknowledge your request. If your question has been answered and you would like to withdraw your registration, please press the 1 followed by the 3. If you are using a speakerphone, please lift your handset before entering your request.

Cori White: Thank you. Today we have a number of slides that Alex will run through, and then at the end we will do 2 quick poll questions that will require a little bit of participation. If you’re not connected to live meeting, we are going to be reading the questions aloud. If you have feedback that you’re dying to give us, you’re also welcome to email us. Anything else, Alex?

Alex Alonso: Nope, I do want to ask one thing. Today because we are dealing with such a special topic that is simulation, we are fortunate enough that Stan and Kristi will be sharing with us some videos for their simulation unit and for their simulation group at Fairview.

Having said that, in order for you to hear what’s going on with the video, we ask that you turn up your speakers on your computer, or that you turn up the volume on your computer as well. If you have problems with that, please submit your questions via the Q&A. we will do our best to ensure you get the sound as best as possible, however please note that there can always be some technical difficulties as they relate to technology.

Okay, so what is our agenda? Our agenda is briefly to run through who AIR is and who the TeamSTEPPS National Implementation team is. Then talk a bit about simulation and the use of TeamSTEPPS in simulation exercises so as to provide some examples of how these are being used for recurrency training at Fairview Health Services.

Then we’ll close out and give you an opportunity to write down information about contacting us at AIR again, or contact our speakers.

As you know, American Institutes for Research is the prime contractor in the National Implementation of TeamSTEPPS Program.

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

Our staff includes health services researchers, nurses and physicians, social and behavioral scientists like me. I’m an organizational psychologist, I’m sure many of you have heard me say this already. The mission of our organization is to better society through our research.

The National Implementation Program was designed by AHRQ and by the DoD TRICARE Management Activity to create a national infrastructure to support the adoption of TeamSTEPPS. The goal was originally to include master trainers through the quality improvement organization under the quality improvement organization program designed by the Centers for Medicare and Medicaid Quality. The other group that was targeted to lend master trainers for the national infrastructure was the Patient Safety Improvement Corps from AHRQ.

The goal was really to make training available to all early adopters of TeamSTEPPS, including individuals from organizations such as High Reliability Organizations, AHRQ ACTION partners, academic medical centers and other types of healthcare professional association.

The ultimate goal is really to spread TeamSTEPPS and create 1200 new master trainers, many of whom are on the line here today, or have been part of the mast training program.

As you know, there are four team resource centers that include Minnesota, which also includes Fairview Health Services where Stan and Kristi are from. We also have Creighton University, the Carilion Clinic in Roanoke, Virginia, and Duke University.

We are supported by QIOs. First is Lumetra, who was the QIO for California, and Delmarva Foundation, the QIO for Maryland and DC.

We are also supported in research capacities by the Group for Organizational Effectiveness out of upstate New York and Booz Allen Hamilton in McLean, Virginia.

As mentioned earlier, our title sponsors are the Department of Health and Human Services, specifically the Agency for Healthcare Research and Quality as well as the Department of Defense and the TRICARE Management Activity and specifically the Health Care Team Coordination Program under TRICARE.

The AIR project team is led by Dr. David Baker who is an organizational psychologist and has a dual appointment as a professor for the Virginia Tech Medical School at Carilion Clinic.

I am the Deputy Project Director for research. Deborah Milne, who many of you know form the collaborative earlier this month in Omaha, is the Deputy Project Director for outreach and user support. Cori White is an administrative supporter, as well as Rachel Greenberg who provides support for outreach and user support.

We are all part of an interchangeable team, and we can all be contacted as shown here. Please note that I will provide this information again at the end of the webinar.

Today’s facilitators include Stan Davis who is a physician at Fairview Health services and he is the Medical Director of Teamwork and Simulation. Stan, why don’t you tell us a little about your work at Fairview?

Stan Davis: Well that is my title, I’m Medical Director for Teamwork and Simulation, and because of the TeamSTEPPS program and our In situ simulation work we are now expanding this more rapidly to other areas other than just OB. We realize that that work will take a lot of coordination and effort so I am no longer practicing OB, but am full time at trying to put in place a system of teamwork and simulation for all of Fairview which includes 7 hospitals, and 42 clinics. So that’s my new job anyway.

Alex Alonso: Thank you, Stan. Kristi, why don’t you tell us a little bit about yourself? Kristi is a registered nurse who is the System Director of Clinical Safety at Fairview Health Services. Go ahead.

Kristi Miller: Thank you Alex. My background is OB as well, mostly as a labor and delivery nurse for many years. And then I’ve been a clinical nurse specialist. For the last several years I have been working with Stan and the entire team of people here at Fairview to in fact grow the program as we would say. In situ simulation utilizing the principles that we will continue to talk about today in TeamSTEPPS and also Just Culture to help us become that High Reliability Organization that we truly want to be.

Alex Alonso: Thank you Kristi. At this point I’m going to turn it over to you so you can begin you presentation.

Stan Davis: Okay. Thank you. Today’s topic is TeamSTEPPS and In situ simulation and the idea is that can we look at the TeamSTEPPS principles involved in a simulation that would be on your unit. The units we started out with were OB, but we also have done this is ICUs, but we’ve done it in emergency rooms, and I the operating room. We do have some video around those areas as well too. So this is not an OB only talk or concept. This is something that can be taken throughout any unit whether it is a hospital or even a clinic.

This slide shows that obstetric performance over time has improved. Any type of clinical performance has improved over time, at least in the western world. The idea is that as we get better though, we have some diminishing returns. This is just an element of human performance in any endeavor. The idea is when this happens we can become complacent and that our old paradigm might need to shift.

This is obvious to anyone that has been in the patient safety movement that we need to focus on what are our errors are. But, as errors become harder and harder to identify because they become rarer, it becomes more important to look at different types of modalities to discover error. That’s where TeamSTEPPS and In situ simulation come into being.

Kristi Miller: One of the things that we have been working with people to understand is that technically, we have become very proficient. We have new medication, we have so many different ways to take care of our patients, but it is complex. It’s sometimes difficult to see the patient in the myriad of the complexities. But that is one of the key reasons why we feel teamwork and communication among all of us is so critical. We do not work in the world of Dr. Marcus Welby any longer. Our emergency room or operating rooms are open units. The places all of us are working are very fast paced and complex.

And yet, we all know “To Err is Human”. We still don’t deliver that care all by robots of course. We deliver it with human beings and we deliver it to the patient. We still have issues with multitasking, with hierarchy, with becoming task-fixated and we have other barriers that prevent us sometimes from seeing, so to speak, the gorilla in the room.

Stan Davis: So, at Fairview Southdale, the hospital that I used to deliver at, I was in private practice for 9 years, we looked at are our staff numbers and became interested in well, how many teams would we actually have if we actually had to do a staff cesarean section or my wife had to come in and have a cesarean section,. What would be the possible combinations of teams, given the fact that we have this many obstetricians and labor and delivery nurses and such.

Some of you might be amazed at the number of obstetricians - there at 81. The reason for that is that Southdale is a hospital in a suburban area where obstetricians go to several different hospitals. So that’s how many obstetricians we have on staff and might come in to do a delivery. They don’t deliver there all the time; they come in and out. But this is very common in many hospitals where you have high staff numbers.

So the question really becomes “how many c-section teams are possible?” what is the number of possible combinations and the number is rather large, it’s 381 million. That’s because you multiply those number to get the possible number of teams.

So the idea is that many teams, we can train that many teams. Because there are so many teams we have to look at the idea of what can we do for individuals to make them a skilled team member. That’s where In situ simulation comes into being. Many of you who are master trainers, or know TeamSTEPPS well, know that a big part of TeamSTEPPS is the coaching aspect of it.

What In situ simulation allows you to do is get at some of that coaching. So that’s a different shift in our thinking in terms of there are many teams and yet we can team train, is our team remains constant, but in many areas in healthcare especially when we mentioned OB, ICU, OR, or the ER, team members are coming in and out of that care and so we have many many different teams. So we have to look at how we get individuals to become more skilled in their team concepts.

Kristi Miller: The way that we have approached this is to really implement what we’re calling In situ simulation, which are simulated sentinel events, issues that have been occurring in the unit. What is the unit really paying attention to? What do they think are the glitches perhaps? The type of communication or how they get information from one person to another.

When we started this we were working under an AHRQ grant and so we did do obstetrics events. However, as Stan said, we have gone on the OR, ER, and ICU for different hand-offs as well. In our world we video tape all of the in situ simulations.

The key for us has been that all persons do their real work. No one does and role playing. If you are an anesthesiologist, that is the work you do. If you’re an RN in Labor & Delivery or in the nursery or the ICU, you do your own work in your own place. It is the real people. Doing their work in the real place of work and that creates a huge psychological fidelity for that person.

What we add to it, is we don’t just have people, for instance as the airline industry calls flying the plane. We want them to learn how to manage the flight, so we use distracters to cause team stress. This can be as minimal as someone calling them in the middle of their scenario to ask a question. It could be as much as the patient doesn’t speak English. For instance in an OB patient, the patient is struggling with fears and has no prenatal, as well as an agitated family member who is always interrupting or is asking many questions. A fainting father. Something that would cause them to pull away from their situational awareness of the moment and perhaps get distracted but also where the team has to make some kind of decision and talk with each other is what we’re trying to create.

The focus is all about communication and teamwork. In our case here we are not specifically using our In situ simulation for how to do the work of being a nurse or a doctor. Many people around the country have Sim labs. There is very excellent training for that. But in our case we’re focusing it all on communication and teamwork.

So, we’re going to use a little help for getting up our first WCCO video. Maybe Stan you want to set it up.

Stan Davis: So, this was some normal TV coverage that we received around our In situ simulation. In a quick 2 minutes it shows you what we’re doing. A reminder: you may have to increase the sound on your computer.

[Begin video news clip]

How do you respond in a crisis? The time to find out is not in the middle of delivering a baby. That’s why Fairview Hospitals are conducting critical event training in their delivery units. To make it even cooler, their high tech patients make the practice sessions very real.

It’s the typical delivery room situation, with a few twists thrown in. Such as the emergency birth of a rubber baby. A robot, actually, which is wired to a computer that tracks its vital signs. A code blue is called when its heart stops.

Even though it’s not a flesh and blood child, the Fairview Southdale Hospital staff work feverishly. Honing their skills as a team. Scenarios can be changed at will. Sometimes mom or baby has to be saved here in the delivery room or in the operating room. But the medical skills are secondary to communication skills. 72% of the time, that’s where the tragedies occur.

In other words, communication problems that might have lead to the medication error. That there was some kind of poor communication between doctor and nurse or nurse and nurse, that kind of thing.

The stakes rise when the robot mother’s blood pressure plummets. Precious time wastes away. All the while supervisors watch from another room and cameras roll as the staff reacts under pressure.

Later, the team shares what worked and what didn’t. Video tape replays the performance. Potential tragedies are sorted out before real lives hang in the balance. But in the simulation no one has been hurt, and there is this very non-threatening environment in the debriefing.

Video clip titled “WCCO Coverage In situ” provided by Fairview Health Services. For more information about this video, please contact Dr. Stan Davis (TeamSTEPPScontact@air.org).

[End video news clip]

Stan Davis: Okay, I hope that the sound worked out okay with that. If there were problems you could send in a question or comment about that. The idea is can you do this inexpensively? The answer is yes. You may have noticed in the video that the beginning of that was with a Russian pregnant woman. She was a nurse from another floor who actually was from Russia.

What she did in essence was provided two important things to the simulation. One was that she created a human element that we didn’t require a mannequin at that point. Number two is that she created the distracter which was the fact that she didn’t speak English, and so how would the team get that information from someone who doesn’t speak English? Do they get an interpreter? Do they call the interpreter phone line? How do they actually get their information? That requires a new element of communication and teamwork that you will be able to see within the simulation itself.

We feel it is very important to not just challenge your team with a clinical scenario but also to challenge them with something outside of the actual pathology of the medical condition. Like a foreign speaking person, like some element of an allergy that might be rare. Like a difficult family member. Something along those lines that creates a second problem for the team so that they have to communicate the element of solving that problem as well.

Kristi Miller: I will say also that you can do a small slice of your event. Like only what is happening in the labor room, and therefore never even use a mannequin at all. Or you could add to that, for instance, as we did, where the patient starts to bleed with an eruption. That risk element has to be understood by the people in the room. They have to call for help. Help comes. Then they make a decision to go to the c-section room, where you can actually create a pretend uterus with a little baby in there. Surgeons and scrub techs can work to actually cut the baby out and that can be their work. It can be very simple, just a slice and you stop, or you can do it in a more standard way.

The components that we provide in our simulation really mirror the team actions that are talked about so wonderfully in the TeamSTEPPS curriculum. We provide a briefing, and then we run the scenario as if it’s your work for the day, and then we follow that up with a debriefing. During the actual scenario we’re expecting that those teams then will huddle when something changes. So actually were modeling what we’re trying to teach in the TeamSTEPPS curriculum.

The exciting part is that it doesn’t end just there. You can actually do quite a bit of follow-up form the simulations, which we’ll talk about in just a minute.

Stan Davis: So a briefing is a planning as you understand from TeamSTEPPS. It gives everyone a shared mental model for what it is we’re working on. In terms of simulation one of the things we’ve found is trying to simulate too many outcomes. One of the things that worked well is to suggest that we are working on communication and teamwork. Clinical skills are important, but that’s really not what we’re looking at in this particular exercise.

You keep people into the outcomes we’re really getting at, which are communication and teamwork and that you will be the participant. You as the participant will be some of the people reflecting on that. We don’t interrupt the simulation to all of a sudden say “oh you didn’t use a check back close loop communication there”. We let the simulation run and then let people identify that later. But the briefing allows everyone to understand that this is a trust worthy exercise. We’re not going to be handing out any pink slips. This is a learning exercise; it’s all about the learning. How can we grow from this experience?

Kristi Miller: The other thing we do during the briefing is to allow them to touch that mannequin, understand how that mannequin works since they need it. We try to really encourage them, whatever they’re doing, to do it as if it was real if you have to make a phone call, do it. At most of the places, we don’t even use an overhead page that is a mock. We just go ahead and page it and let the people come so that we can also test how our processes are working.

When people have asked us “well we don’t have a budget for this” or this seems a little much to do. I wanted to reiterate that you can do a simulation on a shoestring. If you use that concept of writing your simulation: what is your patient’s condition? What are your distracters? Do I want to have that interrupt the team a little bit? What physical triggers do I want them to notice? As Stan said, not have 5 triggers, or have anything too complex going on, but to have it as simple as possible that really allows the people to talk to one another and get going.

Here we used an actress to play the mother. I do want to say something about the family members and the people that play the patients. In the majority of the hospitals that we’ve been doing this – we’ve done over 75 simulations now – they have used people from their community to be the family. It has proved to be an absolutely rich experience, and during the debriefing when these people that are non-medical people play these roles actually speak up and tell the nurses and the physicians in the room what it felt like when they were talking about them or talking over them.

There are many different companies – Guamard is one of them – that can provide that psychological reality with the fetal monitor or other kinds of cardiac monitors. So you can actually create the real deal to help people feel like they’re actually doing their real work.

The biggest piece that we have found that assists us with communication is noticing that the patient’s condition changes. There’s the nurse at the bedside who sees it, and calls for help. As we see here with the physician entering the room where they have to talk to one another and set this physician up with a sense of urgency.

Stan Davis: In terms of complex scenarios, obviously there are lots of mannequins on the market. The more complex scenario in our OB world was that we actually took the OB patient from the delivery room into the operating room actually cut out a baby, as you saw in the video and had that baby as another mannequin that was then part of a neo-natal resuscitation team. So, simulation can obviously be simple or complex. Obviously it would be better to start out with a simpler scenario. Again, going to the OB example, the OB example would be simply having the patient in a bed that is an actress and have them have a particular problem and you don’t’ have to have any mannequins.

Kristi Miller: I’m going to show you two other videos now, sort of back to back. One of them is the physician entering the room and you will hear how there was an issue with situational awareness. And we’ll talk about it. We’ll try to debrief it a little bit when it is over.

Alex Alonso: Kristi, I’m just pausing it for a bit to let it load. Some folks indicated that it was playing for us while it was still loading for them. So I’m just going to give it a minute to load. Then we’ll go from there. This is “situational awareness poor”.

Kristi Miller: Okay.

Alex Alonso: I think that’s it.

[Begin video clip]

Video clip titled “Situational Awareness Poor” provided by Fairview Health Services. For more information about this video, please contact Dr. Stan Davis (TeamSTEPPScontact@air.org).

[End video clip]

Stan Davis: So, that is a video that we use around situational awareness. We’ve used that now for a pre-simulation piece for the participants in the simulation to show how people can lose situational awareness. The next video is now a team entering the operating room. We should also give this some time to load up. Watch this video and ask yourself who is the leader in the room, and why are they the leader in the room? What is it about their behavior that makes them the leader or not the leader?

Cori White: While we’re giving this a second to load, I’d like to remind you all that if you have a question, when you’re entering it in the LiveMeeting Q&A tab, to please actually type you full question into that box. If you just use the little hand icon, we don’t know what your question is.

Kristi Miller: Okay, do we have sound here?

Cori White: Alright, we can try it again, if you like.

Kristi Miller and Stan Davis, simultaneously: Yep.

[Begin video clip]

Video clip titled “Human Factors 3” provided by Fairview Health Services. For more information about this video, please contact Dr. Stan Davis (TeamSTEPPScontact@air.org).

[End video clip]

Stan Davis: So, the anesthesiologist – typically when we show this, people will say “Well, the anesthesiologist was in charge.” Which is actually easy to see. The reason that he shows leadership is around call-outs. What those call outs do: “The Succinyl Cholene is in… cricoid pressure being applied.” These call-outs create a shared mental model for the rest of the people in the operating room.

As many of you know, in the operating room, the anesthesia team is behind the blue drape. In this case, the OB team cannot always see what they’re doing. So, by calling out, he creates a shared mental model, so that the OB team is simply waiting to hear when to cut. So that they know to be ready, because it’s like music to them. That’s why we put the countdown there, because it creates a countdown around where the team is going. By calling out, people create a shared mental model, which allows for more efficiency, and actually in this case, calmness in the OR.

Kristi Miller: Right. What we have found as we have done these simulations is that, sometimes when you think about TeamSTEPPS – the 800 page book that weights so many pounds, and it has so much wonderful rich information in it – people cannot take it all in at one time. We have found that giving it to them in doses that can mean something to them in their real work has worked better for us.

In the human factors field, we believe – remember we said that every individual who works in healthcare, we believe you can know this and be able to use this, are these three things: situational awareness, standardized communication – such as SBAR and closed-loop communication in particular are ones that people have difficulty with, or that need to be emphasized, especially in an emergency situation – and then help create the shared mental model.

The more simple way that we have looked at this is that each of these comes to the moment with our own perceptions, our own library of our experiences. It is what we bring to the moment. Truly, our situational awareness is the meaning you give to the observations that were seeing right in front of us, and it’s all about meaning. Each of us even on the phone call right now has our own situational awareness of what is going on. Stan, if we are going to be that team where I need to speak to you, we actually have to communicate with one another.

The SBAR is that wonderful way to give the short quick information to you. It’s almost like information going out. The call-out is another example of that, and then closed-loop communication is communication coming back in. it’s closing the loop.

By me giving out information and your repeating it back to me, the accountability comes in when I say “that is correct” or I give you an edit to what you are just saying. This then creates, to us, our shared mental model of team work. Then this can become your elevator speech almost when you’re talking to someone about why in the world you want to do this. It becomes the heart of your presentation when you go to the board room or to talk to the CEOs.

There are challenges though, for teams. There is actually a context when you have to use these things.

Stan Davis: Right, and my feeling of real “ah ha” around doing the simulation and being a practicing physician at the time was that when I am going into a room to deal with an emergency or actually any point of clinical care, in the past, I would usually think about what’s the differential diagnosis as to what’s going on in the room. I realized that as a trained professional, and now out on my own and board certified, that I really should have the differential diagnosis down by now. What I had to start thinking about when I entered the room was: am I getting the information I need from the nurse so that I can get up to speed on the current clinical situation?

So basically, what I’m saying, if I was to say it in TeamSTEPPS parlance, would be I need to get an SBAR so that I can have a shared mental model with the nurse as to what we can do to effectively treat and help the patient. So that for me was a big thing. I realize that by entering a room, a doctor is almost by definition multi-tasking, because many people want the doctor’s attention: the patient, the nurse, maybe a family member. At the same time, the doctor is trying to figure out what may be going on clinically. So then multi-tasking actually puts me at a disadvantage. So for me to clearly get on board and share my mental model I need to get information from the nurse in a standardized format, which the SBAR is.

Kristi Miller: The other thing I’d add to that is when you help people understand their environmental cues like Stan was talking about, it really does help them know not only what communications to use, but when to use it. We found that whenever the clinical patient’s condition has changed, when a new team member enters the room or moving the patient somewhere else in you hospital or clinic environment, or you need some help from somebody else in a different department always seem to be the big areas where we need to maintain our vigilance to use our communication teamwork skills.

Our point about all of this is that even though we’ve focused so much on the simulation and how to run the simulation, we are really using the simulation as a prop to get us to the debriefing. The debriefing is the meat of what we are trying to accomplish. That is the place where the interdisciplinary team sits around the table. Actually, for some people, it’s having a conversation with another colleague that does a different role, maybe for the first time ever. It is their shared learning experience to take this experience together that they actually talk about. We try to create less or no shame and blame. We create a very safe environment where we don’t want people to feel guilty or any kind of embarrassment.

Very often it creates the very first opportunities for doctors and nurses to speak to each other. Maybe a talk between a secretary and a physician or somebody form the blood bank coming in and actually talking to a team about how in the world to get blood from the blood bank. We run the video, and we stop it at different junctures, and let the participants talk about it. We try to remember that it is their debriefing, not ours. Although, we do do a little bit of just-in-time education. It is only significant that we allow them really to come up with the real ideas, and they do.

So now we just want to show you one other quick video that was – you’ll see a little snippet from an actual simulation, and then how it was talked about in the debriefing. As that’s coming up, just to remind you that we did use patient actors in the labor room. You’ll see another RN coming in the room. Then how Stan pulls that all together in the debriefing and lets them talk about it.

Alex Alonso: Kristi, which video is that?

Kristi Miller: It has the world “Northland” in it.

Alex Alonso: So, it is downloading as we speak, so let’s give it a sec.

Kristi Miller: Sure, let’s give it enough time.

Stan Davis: The thing with debriefing – my biggest concern in doing it was my ability to facilitate a debriefing, since this was not anything I was trained in. when we originally started we worked with some airline pilots who had done thousands of debriefings out of the cockpit simulators. Two of the things that I would take away from that, that they taught me that I would like to pass on, are: Number one is to try to just get out of the way. These people are professionals. They’ve been doing nursing and doctoring for X number of years, and they know quite a bit. So it’s easy to learn from them and have them coach others within the debriefing.

Obviously there does need to be a role for facilitation, but I always tried to remember going in to debriefings that it would be helpful for me as a facilitator to try to stay out of the way. Secondly, in terms of people’s comments, it’s important to take them down and write them in a way – we use a white board where we actually take down the comment – to show that your comments are being heard. This is critically important for people to understand that exercises that they’re doing are important to administration and to the improvement of the unit itself.

What happens is that it’s not just about learning about teamwork and communication, but that your debriefing actually can help with process improvement for your particular unit. Once people hear that they are heard. Once they feel that they are heard, they then begin to come in to the process more. That’s an incredible business principle in terms of getting the camaraderie going. Getting people interested in process improvement, teamwork, and communication.

We can roll and see the video.

Alex Alonso: Okay.

Stan Davis: Thank, Alex.

Alex Alonso: No problem.

[Begin video clip]

Video clip titled “Northland Event Set 2 Debriefing” provided by Fairview Health Services. For more information about this video, please contact Dr. Stan Davis (TeamSTEPPScontact@air.org).

[End video clip]

Stan Davis: I guess what I was trying to get at – I’ve watched that a few times, but I would say that that is not nitpicking to expect an SBAR or any kind of communication when you first come into with room. I’d also like to say that in watching myself, I’ve realized I am talking a lot but I’m trying to facilitate how that behavior could be changed through some TeamSTEPPS principles. That’s where the facilitation can be very helpful. People watch themselves and then say “okay here is your behavior now. How would these behaviors in TeamSTEPPS help to improve this situation?” So, that’s where the debriefing can be very powerful.

Kristi Miller: This is the start of thinking about how in the world can you follow up after having simulations, especially if you do multiple ones. I’m just going to give you a little bit of what we learned. We have done a phase one with our simulations, as well as a phase two after our phase one, where we did 35 simulations in OB units around 6 hospitals of Fairview.

We sort of coined the ideas of breeches in safety. When we’re talking about both things that have happened from a healthcare point of view –that you see on the left hand side of this pie –and from the Human Factors point of view – that that we call “active failures” on the right hand side. All of this data is taken from our debriefing. In other words, it is our participants talking in the debriefing telling us they noticed that was a failure.

We had over 24.2 failures per simulation if you took them all together. This was the “ah ha” I have spent years as a nurse working in later shifts with process issues, green belt, six sigma, lean, doing all kinds of process things. I have spent a majority of my time – which it is true we must fix the faulty processes, it’s not about bad people it’s about faulty processes.

What was interesting to me if you look at this pie on the left hand side: Policy and Procedure, over 24%, and that is either not following a policy or procedure, lack of role definition, a lack of knowledge skills or training, don’t know what the policy is. People mentioned – and we counted – equipment: either technical failures or not being available or in the right place. Then system processes which is interdepartmental communication, services, reports, information, products not available. If you look at this, that side of the pie was 49.8%.

Interestingly, the other part of the pie was 50.2%. That is our failures with communication (close-the-loop, SBAR, did the guest receive the information, did they inquire back and ask about things, standardized language) were issues that popped up that people talk about, as well as situational awareness and shared mental model. For me, I realized these are really 50-50 in our data. That told me that if we spend no time on really paying attention to the communication and teamwork issues, we are never going to be able to become the high reliability organization that we really want to be.

What we’ve done for you here is if you get copies of the handouts, is that this provides beautiful definitions that you will be able to have. As Stan mentioned, we used big pieces of paper on the wall, and wrote all of these things down so that we could capture their comments and really have that solid data to be able to show our administration why this work is so critical.

I think we’ll get ready now for our last video. Then we’re going to talk a little bit about it. One of our biggest issues in all six hospitals was being able to – in a timely manner – get units of blood to the patient who was hemorrhaging in the operating room. This is one of our sites – Riverside – put together this montage of “Got Blood?” This was put together from many many different simulations. You’ll be able to pick out what the issue is here very very quickly. Then we’ll talk a little bit about it.

Alex Alonso: I’m going to give it a second so that everyone can download their video. I’ve noticed that we’ve had quite a few questions about PowerPoints being available, and whether or not this PowerPoint will be available. It will be available through the handouts option here in LiveMeeting, which is in your top right hand part of the screen/software. It’s an icon that looks like 3 pieces of paper. I would like to point out that we certainly can work with Stan and Kristi after this to see if their willing to provide us with the actual PowerPoint itself. I’ll leave it up to Stan and Kristi.

Stan Davis: The PowerPoint is fine, the problem is that we do not have permission to share the video outside of an educational purpose, and so we cannot share that video. The WCCO video obviously can be shared. But the video of our staff members, that has not been released from the legal perspective, so we can’t do that. But with the PowerPoints, anyone can have those at will.

Alex Alonso: Yes, I should have distinguished that, I’m sorry Stan. We certainly cannot distribute the videos either because it creates a second wrinkle for use with the American Institutes for Research. Certainly we cannot distribute that other than for educational purposes, and you shared that with us, so we don’t want to create that kind of situation. I’m going to play the video now. “Got Blood?”

[Begin video clip]

Video clip titled “Got Blood?” provided by Fairview Health Services. For more information about this video, please contact Dr. Stan Davis (TeamSTEPPScontact@air.org).

[End video clip]

Stan Davis: Well, I don’t know if that’s familiar to any of you, but this is familiar to me as an obstetrician. I know it’s familiar to surgeons and people that work in ERs and maybe ICUs as well. That’s a fairly typically scenario in a hemorrhage situation. When we realized that his was going on over and over and over again, we realized that what we’re missing – go ahead, next slide- there has to be a prioritization system for that.

Actually, we know what that is, it’s an FMEA – Failure Modes Effects Analysis – and Joint Commission requires one of these every year out of a hospital anyways, so we figured why don’t we do it for our simulations? You don’t have to do it around actual care, but to do it around a simulation, what we realized was we could take all of the failure modes – all of the things we thought went wrong – look at the them in an organized way, and then prioritize them. That’s basically what an FMEA does for you.

As the “Got Blood?” illustrates, the getting blood to the operating room in a quick fashion required some process improvement, obviously. We then, worked on that, and the next couple of slides are about that, how we worked on that.

Kristi Miller: The one thing I want to just point out to you here is that we looked at both the process issues and the human factors, the active communication. You see the first two things are more process: how we order, what roles people have. We also found that third one: both how we talk to the lab by saying when we require blood, and they say ‘it’s coming’, there’s no specificity in that. “Blood is on its way” It doesn’t give the people at either end any kind of closed loop communication about what the reality is of the timing. Also we talked to the physicians ordering the blood. Just yelling it out into the air, and not talking to someone specific. All of these things cause a delay in not only receiving the blood, but a delay in care.

As we looked at that, we created at different degrees around our system, it’s still being rolled out, kind of a “one sheet” that is lime green. We had clarity around the lab orders, so that the doctors who were up to their ankles in blood didn’t have to think about all the different lab estimates they wanted, you can see it in the middle there: our physicians decided on the hemoglobin/platelet, INR/PTT, fibrinogen, and a type and screen for X number of units. They could also say whether they wanted it to be type specific or O negative.

They learned that there was a huge difference in the timing if you had to draw the blood on the mother, cross match and get type-specific, that was 40 minutes. But you could get units of o-negative blood in less than 20 minutes. We created the pink, lavender, and blue tubes in a biohazard bag, which we put by the anesthesiologist in the operating room. So that everything was there and the blood could be drawn quickly. We also communicated where they would call the results, we all had issues with them calling results out to some unit versus, right directly into the OR where they really needed it. We could order blood for both the mother and the baby.

So, what does this do for us in a TeamSTEPPS parlance? It creates a process, but it also creates a network for communication and teamwork between two departments. The situational awareness that the green sheet created when it was received in the lab was “We’ve got a mother that is bleeding too much.” So the people in the OR and the people receiving the lab specimens have the same situational awareness about what is going on. Really the standard communication was “I’m in trouble do this first.”

So, those two departments have that shared mental model about what lab channels to be drawn; exactly how many units, the component types, and they have clarity around the timing. Because if they make continuous phone calls asking the lab “Where’s my 2 units? Where’s my 2 units? Where’s my 2 units?” The lab let us know, the blood bank let us know, do you want 2 units, 4 units, 6 units, or 8 units? There was confusion from that. So this brings that clarity. Once you ordered something you know how long it’s going to take to get to you. From just a practical point of view, if you never specified a nurses aide or someone to actually physically go to the lab pick up the blood and use cross check and clarify that as well.

Stan Davis: I’d like to just add that that’ a key point, though, that the process and roles being defined actually end up being a team requirement. How if your team going to decide that? Obviously you can do that in a briefing, or you can do that around what is your policy, or how do you run your operating, or how do you run your operating room.

Kristi Miller: So, to sum up everything what we’ve said: breeches in safety will be inevitable if we don’t mitigate them because we work in a complicated system. As we said before, we have a culture where safety is assumed, but not assured through training individuals how to have clear communication and teamwork as well as navigation of processes.

Very often we rely on the expert individual because they have a certain bunch of letters after their name, but we don’t rely on teams of experts that are working together for the plan of care. We know that our current teams who don’t have stable membership, they don’t have constant leadership, they have very high variability and they rarely train together, and nor do they have the skills and communication and teamwork that our current environment demands.

Our bottom line here is that a team of experts is not an expert team unless you train people to do so.

Stan Davis: Why don’t you give them the information there?

Kristi Miller: Oh, I have a couple other things here I want to be able to have you know that there are companies that you can get some of these simulator pieces of equipment. If you get our handouts you can also see that we’ve written some articles that will help you to know a little bit more about what we’ve done. They’re on two different slides.

Stan Davis: The only thing I would add is that we have nothing to disclose, we don’t have any relationship with any mannequin maker or anything like that.

Kristi Miller: Oh, no.

Stan Davis: We just know there are several big ones: Laerdal, Guamard, Limb N Things, SimMan, there are a lot of different manufacturers out there. Let the market work.

Kristi Miller: It’s easy to find them you can go on the internet and find them, but we thought we’d just offer you a couple of ideas. So, you can open it for questions, I believe, Alex.

Alex Alonso: Okay. At this point, Cori, I’m going to turn it over to you so that you can field the questions, or make sure that Stan and Kristi get the questions.

Cori White: Okay. The first question that we have is: “During the debriefs, do they watch their video?”

Stan Davis: Yes. They do. What we do I we have everyone start out the debriefing by having a quick sound bite so that everyone on the team has actually participated in the debriefing before they actually watch the video. That allows everyone to speak up and we typically use the three questions for debriefing: “what went well and why?” “What didn’t go so well, and why?” and “what might you do differently next time?” We let people answer those in sort of a sound bit format, so that we can move around the room.

We them watch the video, with stopping the video at certain points to let people comment. The comments are then taken into the context, very often, of TeamSTEPPS, as we showed you in the one video. At the end of the video, we go around the room again and let people make any further comments or any learnings that they might have had from this.

We also make sure that people get their ideas back to the manager or back to someone who is a leader on that particular unit because what very often happens, as you know, in medicine we tend to ruminate about our errors, and about our problems, and we ruminate about these things for a couple days “ok, I wish I would have done this, or maybe I should have done that.” So that rumination can lead to lots of great ideas, so you want to try to collect those too, and make sure that people understand that they may come up with an idea two days later that we certainly would like to hear about.

Kristi Miller: The other thing that I might add in is that we have also been filming out debriefings. That allows the manager or the leaders or even the people that couldn’t attend that day to get an idea of what goes on. That’s another thought.

Cori White: Alright, great, thank you. We have a question here about accessing the video for use in your own location. We have covered that before. We are unable to distribute the videos because we only have permission to use them in an educational context like this one. So we apologize, but we cannot pass those on.

The next question we have is: “Who should perform the role of debriefer? Could the leader of the clinical team or one of the learners ever be the debriefer?”

Kristi Miller: I’ll let – Stan may have some comments to add – but, we are using anybody that has the skills to do it, and the will to do it. I think that either it’s somebody that is neutral, some units prefer someone that is outside of their own unit, to be the debriefer, and others are using a doctor and a nurse within their own team and it works really well. We have done both, and have seen that both work well. I think you have to always make it fit the unit and fit the department.

However, I think we’ve seen that some of the debriefings have gone better if at least there, in some ways either a content expert is some manner about teamwork and communication, and/or. It is an either or, but they have to be a content expert for that particular field of clinical work. Because Stand and I, we know OBs but we have been just as effective debriefing ERs and ORs and ICUs because we’re really talking about communication and teamwork.

Stan Davis: It actually, as someone who facilitates debriefing, a master trainer would have a really great background for that position, because you would have the TeamSTEPPS concepts down, and then it’s a matter of trying to get out of the way, but also at the same time, trying to create a more Socratic environment than a didactic environment, if you can get other people to coach team members.

In other words, the team members who are participating in the simulation can coach each other during the debriefing, that’s incredibly powerful. I actually think that’s one of the reasons this works so well, is that what it teaches people is that they can coach each other, because there’s not the shame and blame that we typically have after a bad event. It’s just been a simulation. We’ve just been through a pretend exercise, and so there’s not that guilt that goes along with some of these things. That ability to coach each other is incredibly powerful as that team moves on as that unit moves on because then they accept that coaching in acceptable.

Kristi Miller: I think one of the pitfalls people run into is it’s easy to want to problem-solve during the debriefing, and people will tend to go to the technical, or problem-solving, person with communication issues. Part of the facilitator’s role is to continually pull them back to the communicational and teamwork pieces. So three basic questions “what did you feel went well today and why?” The why is very important. “What do you think might have gone better, and why about communication and teamwork?” and “What would you like to do differently next time?” If you can continually focus them on that it seems as if the conversation really just blossoms, and they do figure things out themselves.

Cori White: Okay, great. The next question is “What are the benefits of using mannequins? In other words, how do you justify that expense versus just doing it on a shoe string?”

Stan Davis: That’s going to be a very individual thing. It really depends on what you’re simulating to, and who you’re simulating with. The mannequins are extremely helpful in the operating room because you obviously are not going to use a person to have something on their belly that you would cut out a baby and drape them, that kind of thing. That would require a lot of that particular actress. The second part of that is that the anesthesiologist and CRNAs want some kind of graphic, they need their typical blood pressure and O2 monitor to make it realistic. That’s an extremely helpful part.

When you’re looking at skills in terms of – let’s say you were running a shoulder dystocia drill – or let’s say you were practicing how to put in a chest tube – then you do want a more sophisticated simulator, because then you will look at those skills in a more realistic light. From the communication and teamwork standpoint, we feel that mannequins are helpful, but they’re not the end-all-be-all. You can do this with a standardized patient, as they’re called in the simulation world. A standardized patient is someone who is an actor and has a typical scenario or script that they’re running from.

Cori White: Okay. The next question is: “Have you done simulations in any other areas besides OB? Have you done any in Psych?”

Kristi Miller: We haven’t done psych yet, but we have been talking to them a little bit and we’re getting ready to do some with the pediatric world around rounding with physicians in the rooms. The one that I think might pertain more to your question which we’ve been doing in the ICU, they’re doing one again soon at one of our hospitals around the handoffs of the average patient coming from the operating room to the ICU. This is a very critical handoff with very ill patients at that moment in time. That unit has learned a lot about how their handoffs could be better.

We actually had a an MBA, a CRNA, and two nurses in their first simulation they found they were talking over each other or talking at the same time and even one of the nurses had a stethoscope in her ear when she watched the video she recognized that she hadn’t heard anything the person had said, and how critical that was. That caused them to really work on that process. The other thing that they do even in the operating room is the patient coming into pre-op, what happens there. The information that is obtained in pre-op and then how that information gets to the people in the OR. I think for us you’re thinking about how is either information about the patient documented and shared between people, or transferred between care givers, and any of those can be simulated.

Stan Davis: We’ve actually thought, at least from the psychiatric perspective that a difficult patient or a psychotic episode would be a good thing to simulate. We have not done it yet, but that would certainly be easy to do in terms of you would not need a mannequin per se, but would need a pretty good actor for that one. The idea would be you have your script; you might have a few distracters in terms of a family member. Then, what do people do in response to a true psychotic episode? What kind of information are they transmitting, and are they asking for help? How do they ask for help? That kind of thing.

Cori White: Okay, thank you. The next question is: “How did you get buy-in from specific departments? How did you accomplish getting the entire team to participate in the drill or simulation?”

Kristi Miller: Stan probably has some thought for this. I had the biggest success by explaining first of all to the leadership the criticalness of 72% of our sentinel events for our errors that we are having in healthcare have to do with communication and teamwork. Then, what are the prominent events for that unit, and what are the probable costs. Both the human cost as well as the financial cost.

Once you do one simulation that create s abuzz in the unit, because that means if you’re doing during the day or in the evening or on some shift in the middle of all the work and amazingly even the people that are not participating, that are taking care of the rest of the patients, all the rest – Stand and I have stopped by before to give them a briefing about what’s going to be happening, if somebody calls for help or needs something, please bring it in to them as if it was a normal day. Then afterwards just to pop by and talk to the rest of the people on the unit and there was a real buzz in curiosity.

In fact, in some of the units where we had staff saying oh I’ll never do that. Well, once they did a few, and we stopped in a certain unit and moved on to another one, they were like “Well, wait a minute, why didn’t I get a turn?” Also if you use other people, a few people each time, be it either leaders or other staff, to be observers, like they don’t have to participate, they could come into the briefings, and sit in the background and listen to the debriefings, that’s where they catch a lot of the enthusiasm.

Stan Davis: I think I should try to say this as simply as I can, because your question really gets to leadership and how does all this work. The simplest way I can answer it is: get your early adopters to do one of these, show them that their voices were heard through basically procedural justice “we heard you, here’s what we’re changing because of what you said.” Then, that will create the buzz that will allow people to commit and want to jump on board.

Cori White: Ok. “What percentage of an average unit’s personnel have had a chance to participate in this simulation, not just participate in a debrief? For example, do we you have a critical mass of people immediately involved in the simulation experience?”

Stan Davis: Yeah, that’s a great question. We right now are in phase 2 of an AHRQ study that is looking at that in terms of dosing for the in situ simulation. All I can tell you from that study right now is that we have reduced our adverse outcomes at a smaller hospital where people got a lot of doing around the in situ simulation and that every obstetrician went through it and most of the nurses went through it. So we actually are showing some outcome data around participation, the in situ simulation. So that was a reduction in adverse outcomes, statistically significant compared to control that got no simulation.

The question goes to how many people actually participate and how can you do it? At a smaller hospital, obviously it’s easier to do. Once we got some buy in then it seemed overwhelmingly that people wanted to do it. In a bigger hospital I think it is going to be more difficult, that’s where you have to get your early adopters. So I can’t tell you that there’s particularly a critical mass. I actually think that what’s going to happen is that as we do more and more of this, that we will realize its value and that we will need to do it on an every-other-year basis or an every-year basis. It will be very much like the airline industry where we’ll want to look at people’s communication and teamwork on a more regular basis.

My own opinion too is that until we can get the private practitioners involved, financially they are not all going to come on board. We have had some private practice docs doing this, but again, they were kind of the early adopter types. The later adopter types typically aren’t going to do this kind of thing and are probably going to require financial incentive through their malpractice carrier or through their hospital or something else.

Kristi Miller: I will say, though, that when we looked at the 35 simulations that we did in 6 hospitals, we literally affected close to 1000 people when you consider you have primaries, but you also have people from the lab, people from the pharmacy, people in the operating rooms. We also had extraneous people that would come to our debriefings, so you can affect an enormous amount of people in the hospital even just by doing 20 or 30 of these simulations in your different departments.

Cori White: Ok, thank you. The next set of questions I think you’ve answered a couple of these. So I’ll read the whole thing anyways just so we can make sure they’ve all been addressed. The first one is “How often do you hold the simulations?”, “Do you find it difficult to get participants?” and “Do you hold separate simulations for skills versus communications?

Kristi Miller: We have allowed the departments to decide how frequently they want to hold them. I think it’s difficult to do more than 1 a week. But we have done 3 or 4 in one day. With an operating room that was getting ready to open in a small hospital, we did 4 simulations in one week. So really, that’s really up to the people who are running them, what their energy level is, how they want to get organized. Some departments only do it once every 5 to 6 weeks. I would say that it’s been different at each place.

Stan Davis: Yeah, different at each place, and it’s obviously just based on your logistics what you’re able to do, in terms of research on degradation of behaviors, we don’t have anything that way. All I can tell you is that from the airline industry the FAA requires yearly cockpit simulation. United did its own internal research on degradation of good cockpit behaviors, and they found that that occurred at 9 months, so then United Airlines actually, those pilots go into a simulator every 9 months. So that’s all I can tell you about degradation of particular skills.

Cori White: Ok, the last question that we have through LiveMeeting right now is: “Do you have a tool for the questions that you use in debriefing?”

Kristi Miller: Well, for one thing you can read about it in one of our articles in more detail, but we are using those three questions that we keep repeating. They sound overly simplified I’m sure. We ask the group “what went well and why?” We ask each person as they watch their little part of the video, and “what do you think could have gone better, and why?” and “What you think you’d like to do differently nest time?” Those are the main questions. I want to reiterate that we are focused on communication and teamwork, and currently different units have utilized different venues in orders to keep technical skills. So Stan and I have not been leading that as part of the work.

Stan Davis: So, we didn’t answer that question about did we simulate to the objectives, and we have. Not as leaders for that, but as observers of that sort of thing. It can get confusing if you are simulating to clinical skills and communication and teamwork skills at the same time. So, we’ve at least found initially that we want to simulate only communication and teamwork skills and leave the clinical skills separate for another discussion at another time. That’s not to say it can’t be done, and we’re actually looking at ways we can try to do that. But that is a delicate balance, because you’ll get into a debriefing and find that people want to talk about certain things, and it’s truly not the focus that you want for that particular scenario.

Cori White: Ok, that’s all the questions we have through live meeting right now, again if you have a question please use the Q&A tab at the top of your live meeting window. Operator, do we have any questions on the phone?

Operator: Ladies and Gentleman, to queue up for a question, please press the 1 followed by the 4. One moment please for the first question. This question is from a military caller. Please go ahead with your question.

Participant: Hello, my question is do you guys offer TeamSTEPPS classes that people can attend? We have a brand new simulation center here that I’m a part of, and we have a lot of equipment, and we do try to get TeamSTEPPS involved in the different areas that we have, but it’s a little bit hard to be credible if we haven’t had the adequate training as well.

Stan Davis: In terms of the TeamSTEPPS training prior to, we did not initially start with any kind of TeamSTEPPS training prior to our simulation because our simulation work started before we became TeamSTEPPS master trainers. What we realized as soon as we took TeamSTEPPS obviously was that the fit hand in glove. It’s actually just a fantastic way to utilize TeamSTEPPS. What we have found helped was to create an education piece that was shorter. Basically a ‘TeamSTEPPS for Dummies’ if you will, that looked at those 4 principles that we talk about: positive situational awareness, standardized communication, closed-loop communication with check backs, and shared mental model.

We then had people do that so that when we got into the debriefing we weren’t spending so much time in a didactic fashion. One of the powers of this in situ simulation and the debriefing is to create a Socratic atmosphere where everyone can learn from everyone else because that enables coaching to occur. Coaching is so important to the sustainment of the process, so that’s why I would say if you can get some of the didactic stuff out of the way first, I would certainly do it, but I would not do it in a manner that is too long for people. They will kind of fade out. Try to get the more salient parts of TeamSTEPPS that you want to simulate to and look at in your debriefing.

Participant: Ok, thank you sir.

Alex Alonso: Operator, do we have any other questions?

Operator: No sir. I will turn the call back to you.

Alex Alonso: At this point I want to thank Stan and Kristi for participating today and for facilitating today’s webinar. It was very full of information and I hope that everyone found it particularly useful. Cori, why don’t you load the polls so we can gain some participant feedback?

Cori White: Okay. Here’s our first question. Our first question is “How useful was the information provided here to you today?” If you’re at the computer and you’re sharing a room with someone, you’re going to have to fight to see who gets to answer. We hope that if you’re in the same room, you have similar feelings anyway. I’m going to leave this open just for a minute so that you can answer it, and then we will close the poll and display the results.

We’ll give you just another 30 seconds to answer and if you think of a question while we’re asking you some questions, go ahead and ask it in the LiveMeeting client up in the Q& A tab so that we are able to get it answered for you.

Alex Alonso: Ok, go ahead and close it, Cori

Cori White: Ok. Here are the results from the poll, it looks like most of you are finding this quite useful. We appreciate that feedback. The next question we have for you is: “Would you recommend these webinars to others?” Again this just helps let us know how we’re doing with these, we’d like to know if you want more.

Alex Alonso: Ok Cori, go ahead and close that.

Cori White: Ok. There are your results for this one. It looks like most of you would recommend us, and thank you again!

Alex Alonso: Okay, at this point I want to thank everyone for having participated here today.

If you are looking for more resources regarding TeamSTEPPS you can look for them on the www.ahrq.gov/teamstepps website. You can also find information like the TeamSTEPPS Guide To Action and information about the webinars including a transcript of the webinar. You can also go to the DoD patient safety website which is http://dodpatientsafety.usuhs.mil/.

For information about TeamSTEPPS at AIR or information about contacting the National Implementation Team, you can use any of these telephone numbers and or email addresses to reach anyone on the TeamSTEPPS team.

The last thing I want to do is thank everyone for being here today. Thank you very much, have a great day!

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.