National Implementation of TeamSTEPPS Program Webinar 12:
TeamSTEPPS Contextualized for Contingency Teams

Moderator: Alex Alonso
July 22, 2009
11:00 pm CT

Operator: Ladies and gentlemen, welcome to the American Institutes for Research TeamSTEPPS Contextualized for Contingency Teams conference call. During the presentation all participants will be in the listen-only mode. Afterwards we will conduct a question and answer session. At that time if you have a question, please press the 1 followed by the 4 on your telephone. If at any time during the conference you need to reach an operator, please press star zero.

As a reminder, this conference is being recorded, Wednesday, July 22, 2009. I would now like to turn the conference over to Dr. Alex Alonso. Please go ahead sir.

Alex Alonso: Thank you. I want to welcome everyone to our - the 12th Webinar in the series of the National Implementation Program for TeamSTEPPS Webinar series. Today we have a very distinct Webinar in that we're not going to be discussing the success stories of any of our partners or any of the folks who've been trained as master trainers. Instead, we're going to provide you with a preview of a new AHRQ product, the TeamSTEPPS Rapid Response module, and then talk to you a little bit about some of the field testing that was done during development of this module.

As with all of our Webinars, we ask you to be considerate of others while participating in the Webinar. Make sure to mute your phones to reduce background noise, to not put your phones on hold if you have music or advertisements, things of that nature. And just remember that a conference call can never be better than the worst connection on the call. Now before I move forward, I'm going to ask Cori to give you an orientation of the software.

Cori White: Hello! Many of you are joining us today through Microsoft Office Live Meeting, which is how many of you will see the slides. I know that a number of you are joining us on the phone, so I will address you in just a moment. For those of you who are joining us through Live Meeting, the most important thing you need to know today is how we're going to handle our questions and answers.

If you're connected through Live Meeting, at the top of your window there should be a menu item that says Q&A. If you click on that, a box should pop up that gives you a space to enter questions. If you have a question, we ask that you first ask it there. It is important to us to be able to manage questions appropriately. So if you ask it there, if it's something that's a personal question like you can't get the slides, we'll address it there. If it's something that the whole group would benefit from, then we'll answer it when we get to one of our built in question slides in the slideshow.

So again, the Q&A tab at the top of your screen is the best place for you to ask a question. The question about the handouts I can answer right now actually in advance. If you go to the top right hand side of your screen there is an icon that looks like three little pieces of paper. If you hover over it, it says handouts. If you click on that, that's where you can download the handouts. Those are the slides in single slide per page format as well as three slides per page with space for notes. So those are all provided.

If you are joining us only on the phone, and you have not contacted me yet to receive a copy of the slides, please send us an email to teamsteppswebinars@air.org, and I'll make sure you get those so that you can follow along. For those of you on Live Meeting, next to the handout icon, or rather two icons over there's something that says feedback, with a little square that should be green right now. If you're having trouble hearing us, or you think that we need to slow down, please change the color there and it'll let us sort of have an idea of how you all feel.

So as I said, we're going to have a couple of question and answer slides spaced through the Webinar. We'll have the operator tell you how to put in a question in just a second. In addition, at the end of the Webinar we'll ask you two very quick poll questions. Those just let us know how we're doing, and how we can improve for the future. Operator, would you let people know how to register for a question?

Operator: Certainly. Ladies and gentlemen if you would like 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 speaker phone, please life your handset before entering your request. And I turn the call back over to you ma'am.

Cori White: All right. I think that that's all we have in terms of questions. Again, if you're joining us through Live Meeting, please ask your questions there. It allows us to manage them most appropriately, and make sure that we have a chance to see what people want to know.

Alex Alonso: Okay. And when we - when you type it - when you ask a question in Live Meeting, we ask that you type the actual question in, because we can not address questions that involve raising of hands and things of that nature. Okay.

Today’s agenda is very similar to others; except that we're going to talk a little bit about the National Implementation Program, and then we're gonna talk about the development of the Rapid Response Systems module for the TeamSTEPPS curriculum. We're going to show you about 25 slides from the actual module itself, and talk to you a little bit about how they were developed, and what the theory and thinking behind them was when we put them together.

Then we're going to list some information about how the module was field tested, and what the results of that field test were. As you all know, the American Institutes for Research is the prime contractor for the National Implementation of TeamSTEPPS program. We are not for profit and non-partisan. We're DC based. We have 11 US offices and 12 international offices focusing on health, education, and workforce issues. Our staff varies from health services researchers to actual clinicians, all the way down to social and behavioral scientists such as me.

The mission of AIR is to better society through our research. The actual project itself for the program was designed by AHRQ, and by the Department of Defense TRICARE Management Activity to create a national infrastructure to support the adoption of TeamSTEPPS using staff from Quality Improvement Organizations in the CMS quality improvement division, as well as AHRQ's Patient Safety Improvement Corps Group.

The idea was to make training available to early adopters such as High Reliability Organizations, ACTION Partners, academic medical centers, and other organizations such as professional associations and societies. The overall goal is really to spread TeamSTEPPS and to create 1,200 new master trainers, something that we - a goal that we have achieved to this point.

As you all know, there are 4 team resource centers. There's the University of Minnesota, Creighton University, Duke University, and Carilion Clinic which is now the Virginia Tech School of Medicine. We were supported on this contract by Lumetra, and Delmarva who helped us recruit members of - or staff members of quality improvement organizations. We were also supported by Booz Allen Hamilton out of McLean, Virginia, and the Group for Organizational Effectiveness out of Albany, New York on research and tool development.

As you all know, the title sponsors for TeamSTEPPS, and anything involving TeamSTEPPS are the Department of Health and Human Services and the Department of Defense, and specifically the sub-agencies are the Agency for Healthcare Research and Quality, and the TRICARE Management Activity Health Care Team Coordination Program.

Our project team is led by Doctor David Baker, out of the Carilion Clinic Virginia Tech School of Medicine. He has a dual appointment with the American Institutes for Research, and is the practice area lead for all TeamSTEPPS projects here at AIR.

I am the deputy project director for research and development of tools. Debbie Milne is the deputy project director for outreach and user support, and all things having to do with the TeamSTEPPS Collaborative and listservs, and what not. Cori, who is the on the phone, is also the administrative support person for Webinars and research. Rachel Greenberg is the administrative support person for outreach and user support.

We are all an interchangeable team, and we can all be reached and address your questions as needed. Here is our contact information. Please feel free to write this down, but note that you'll have another chance to see this information.

Today we are joined by a co-facilitator. I will warn you that I'm going to do most of the talking today, because I was the AIR project lead for the development of the TeamSTEPPS Rapid Response Module. Doctor Nikki Schiebel from the Mayo Clinic, is a fellow in emergency medicine, and served some time as the acting practice chair for the Department of Emergency Medicine at Mayo in Rochester, Minnesota.

I’ve asked Nikki to join us here because she was an integral part of the development of the TeamSTEPPS Rapid Response Module. She's actually one of the chief contributors who have served on our strategic expert panel. That was because she was the leader of the Mayo Clinic's Rapid Response System, and is the coordinator of all training for the Rapid Response Rystems at the Mayo Clinic Rochester campus. So we're very fortunate to have Nikki here with us today.

Now I'm going to get into how TeamSTEPPS RRS was born, and where the idea came to develop or contextualize TeamSTEPPS for a contingency team like the rapid response team. And we refer to it as the rapid response system because of the theory and practice around rapid response.

In June of 2006 AHRQ pointed to a need for the marriage of core research tracks. Their patient safety group and the Center for Quality Improvement of Patient Safety has been funding several research tracks around improving patient safety, or increasing patient safety.

Among some of the big ones were rapid response teams, or medical emergency teams and research around those, and teamwork and team training. The goal for AHRQ really was to leverage the lessons learned from both these research tracks, and then marry them such that they could create a contextualized module within the TeamSTEPPS curriculum for rapid response systems.

In January of 2007 AIR and AHRQ started working towards this. What we did was we held a panel of leading experts, Nikki was one of these leading experts who attended this panel, and we discussed the appropriate model for integrating these two tracks of research, as well as building an education curriculum for teamwork in rapid response systems. Several panelists were part of this.

We had leading experts in teamwork, such as Eduardo Salas, as well as leading experts in rapid response systems, like Nikki, like Peter Pronovost from Johns Hopkins, like Brad Winters from Johns Hopkins, like Michael DeVita from the University of Pittsburgh. So, we had quite a few folks who were willing to collaborate and share their ideas or notions on how teamwork should be trained within a rapid response setting.

From that meeting we came out with a design specification for TeamSTEPPS rapid response, and how it should be field tested. We then began developing a prototype based upon this particular design specification. We then moved towards taking the developed prototypes and field testing them at three particular institutions that had varying degrees of rapid response experience, and/or rapid response expertise.

We designed a field test that would help us really identify what a novice learner would glean from the rapid response module versus someone who was not a novice learning, or someone who's an expert learner.

In December of 2008 we submitted the final draft of the prototype modules to AHRQ. The objectives that were identified as part of our specification were one, for participants of the TeamSTEPPS rapid response system module to be able to identify or to define the core tenets of the rapid response system, and what the features of a rapid response system are. These were really based on some of the works of DeVita and the medical emergency team researchers such as Richard Bellomo from Australia.

We also then wanted to define the core tenets of teamwork, including the competencies for effective teams in a contingency team setting. We also then wanted to do something that was a little different from the core curriculum of TeamSTEPPS which was to prescribe and/or identify which team strategy or tool from the core curriculum would be most appropriate during a performance of rapid response teams. Finally we wanted to give opportunities to practice the strategies when appropriate.

This is actually the first in a series of slides that come from the actual module here. You'll see that the first thing that we want to focus on is giving folks who will be trained in this module some type of background as to what it is that we are referring to in terms of core terminology. We want to provide a definition of what a rapid response system is according to the research, and what found in our literature review. Then we get into what TeamSTEPPS is and how it is applied to the rapid response system.

Now we also want to define rapid response teams, because rapid response teams are part of a rapid response system. I think that one of the things that the research is moving towards, and Nikki will speak to this later on from the perspective of a rapid response system coordinator, is that the team is only a small part of it. So the traditional team of clinicians that provides bedside care when there's a sign of acute deterioration is really only a small part of the rapid response system. The system is comprised of larger pieces, and also functions as a whole to ensure stabilization.

I apologize because some of these are disjointed. They don’t actually follow the flow of the whole course. I could not provide all the slides from the whole course because we'd be here all day. But the next phase of the rapid response module systems that we wanted to target was what it is that it takes to implement a rapid response system in a specific facility.

One of the things that AHRQ really honed in on as a core objective for this particular module, or this educational piece was identifying the different stages, or the different types of implementation for rapid response systems. That it doesn’t have to be the traditional three person team that is seen in the early research. It can actually consist of different parts, and it varies according to the resources that are available, and there are numerous types of implementations that occur. One of the things that they wanted folks to walk away with was the fact that you can customize it, as long as you serve or fulfill all of the functions that a rapid response system should fulfill.

Here is the TeamSTEPPS RRS structure, or the recommended structure for a rapid response system. Now keep in mind this is based on the research of Michael DeVita and several other leading researchers in the rapid response system world. Specifically, it calls to the four basic arms of the - or limbs of the rapid response system that they identified in their 2006 treatise if you will.

If you look over the left hand side of your screen, you'll see that the activator is part of the clinical treatment group, and these folks are actually referred to as the afferent limb. Then there's the efferent limb, which is the responders, or the actual rapid response team. You'll see that there's a cavalry that has been called in this particular penguinized model.

Then there are the two other limbs of the DeVita model, which are the quality improvement arm which is responsible for data administration and data collection, and ensuring that there's evaluation of the RRT response or the RRT call, and then the administrative arm which is helping keep all of this information together, and keeping the feedback loop in place.

We just used terms that we thought were - when we tested them out – these these were the ones that seemed as though they were the most intuitive four folks, the ones that made clear sense. So you had an activator, you had responders, who are the rapid response team, and then you had the other two arms. Those two arms are support mechanisms for the clinical treatment side of the house.

Here we provide some background as to what the activators do and who they might be. Specifically the goal here is really to provide some type of understanding that it is not just floor nurse who is caring for the patient. It is actually anyone who could be part of this rapid response system. Again, as with all parts of TeamSTEPPS, we put a special emphasis on the fact that the patient and the family members of the patient can provide information that leads to activation of the rapid response team, and in some cases can actually be the activators themselves.

Here we provide a description of what the rapid response team looks like, and specifically what their goal is, and what their job is. Here's just further background on what the actual activator and responder side of the house is doing. Now one thing that we focus on, and we try to focus on repeatedly in this particular module is - and this was based on a lot of interviews that we did when we were conducting the background research for this with folks who were participating as members of rapid response teams, or folks who were serving as activators of rapid response teams.

One of the things that came across very clearly is that numerous persons had reported the concept that they were greeted by the rapid response team or by the responders with the question, "Well why did you call us. This is not a reason to call us. This is not - you're not following the appropriate criteria." And I should point out that one of the things we do list is what are the appropriate criteria according to the IHI and the rapid response collaborative. We do list what the criteria are, or what some common criteria are.

We don’t list it on this particular slide, but it is part of the curriculum itself. One of the things that we wanted to do away with was the stigma that there is such a concept as a bad RRT call, or a bad activation of the rapid response system. Nikki, I thought maybe you might speak a little bit to that since I've been talking here for a little bit. One of the things that you might recall from development was folks really feeling like there is this, "Why did you call" stigma.

Nikki Schiebel: Yeah. I think we learned this early on in our process as well, that what this whole thing is trying to do is build a culture change. Part of the culture is, you know, if you call for help somebody's gonna yell at you, or, you know, there's gonna be some kind of negative social consequence of calling for help. The biggest factor in making a rapid response system effective is for the teams to understand how important their behavior is, and specifically how they say things has a huge impact on the person who's just activated the call.

If you go in and say why did you call, if you ever use the why word, that's kind of a negative word in our culture, and it puts people defensive. Immediately the person who's activated feels like, well maybe I shouldn’t have called. So what we train our teams to do is - the first thing they say when they arrive in the room is, "Thank you for calling us. What's the situation?"

It's subtle, and you could argue well they're saying the same thing, which they are, but it's how you say it. That is a critical factor in the training, and in teamwork in general is learning that sometimes how you say things is a key feature of how you change culture and make people comfortable in asking for help.

Alex Alonso: Okay. Thank you, Nikki. I do want to address one question that came in. I have used rapid response teams as a way of functioning, so specifically to refer to the concept of responders. That team that comes in and helps the activator stabilize the patient. So if you think about them specifically they could be a respiratory therapist, an internist, and a nurse.

However that is not to be confused with rapid response systems. The system itself refers to all pieces of the rapid response team - or the rapid response system structure, which includes activators, responders, the quality improvement arm, the administration arm that sets the policy for the rapid response system.

So the rapid response system is larger, and I will try to be more clear with the terminology. The module itself is geared for the overall rapid response system, and specifies team tools and strategies for all arms of the system, depending upon who is in action.

Okay. I'm going to move forward here. Here we talk about some of the support mechanisms that exist for the rapid response system. We provide some background as to what their activities, or what their roles should be, according to best practice.

One of the things that we do in the module itself, and we created as with all TeamSTEPPS modules, we created a series of opportunity won and opportunity lost video vignettes. I'm not actually going to show the video, but I wanted to give you a glimpse as to in the module itself, pretty early on what we try to do is show an opportunity lost so that folks can see where potential breakdowns in rapid response system functioning can occur, and where teamwork can actually be applied to help foster some of the better performance, or more effective communication.

Okay. Once we move from the actual background from rapid response systems, and what the actual theory behind them is, and what their structure should be, we focus in on what some of the barriers are to effective care in the rapid response systems, some of the ones that we've seen from our organizational needs analyses that we conducted early on, and then we highlight which ones could be tackled by teamwork.

This slide should look very familiar for those of you that have seem TeamSTEPPS because it really is an updated version specifically for the RRS, and we focus in on some of the most salient obstacles to effective care that can be addressed by teamwork.

Again, one focus that you'll see throughout all TeamSTEPPS curriculum pieces is that we focus on the four necessary teamwork skills. However with this particular module we also identify a few new components or parts of teamwork that seem to be relevant for enhancing the overall proficiency in these competencies. For example, one of the things that we focus on is helping folks develop an inter-team knowledge.

Part of the reason why this particular additional competency is needed is because you're dealing with a system that has multiple limbs if you will. When you're building or functioning on that level that is a multi-team system, you want to develop inter-team knowledge. The organizational psychology research will tell you that inter-team knowledge is used really to build a larger or system level shared mental model. This is a big part of what goes into the TeamSTEPPS rapid response module.

Now inter-team knowledge focuses specifically on building or knowing what's going on within each unit of the overall system. So for example, do the activators know what responders need, and do the responders know what is needed or required for each unit that participates or supports them, whether it be the intensive care unit which the patient might be dispositioned to, or it be back down to the labor - to the actual floor where the patient is being treated once they are stabilized.

Inter-team knowledge as a whole really supports another skill which is boundary spanning, or understanding what it is that goes into serving as a liaison between the different units. For example, oftentimes the activator will be called upon to use some of their boundary spanning skills to provide role support so that they too are - take part in the care of the patient, even though the responder team is already there to provide that care. They will kind of walk through with this team, and make sure that they are providing support as needed to the team during the care of the patient.

Now that is not always the case and does not always happen, but it requires that inter-team knowledge, and that larger system level shared mental model to really build - or build proficiency in this skill.

One of the things that we wanted to focus on when developing this particular module, and by we I'm also referring to AHRQ and DoD, was the concept that there is no one size fits all RRS for healthcare. Unfortunately resources are limited, and not everyone can apply the same number of resources to a rapid response system, or the implementation of a rapid response system.

There are numerous ways that this can differ. What we wanted to do was provide some type of examples of how rapid response systems are being implemented across the nation so that folks could feel comfortable with taking different pieces, and again customizing how it's implemented in different facilities.

Here you'll see an example of one RRS. We talk about a couple of different features in each of these examples. First we talk about how activation takes place. How is it that responders are called? Then we talk about who can serve as a set of responders.

Here you'll note that there are a number of folks who might be added to the rapid response team, or the responder team if there are different conditions met. For instance, transportation services might be included. For pediatric cases you might see someone from the chaplain's office from security or respiratory therapists included.

One of the things we also focused on is how these rapid response systems conduct their training, and how it is that the data collection takes places, and what it is that they're really focusing on when they conduct their data collection.

We also tried to provide a contrasting example, one that focuses on the same core elements but provides a different take on it all together. For example, activation takes place, and it's not necessarily always using a pager. Sometimes it uses an overhead page system as well. They also include family members to be part of the activators, which is not necessarily something that's afforded to family members in the other example. Here you don’t have as large a group of responders, or as large a pool of care givers or care providers from the responder - to serve as responders.

We also talk about some of the training. By contrast here, the training is really in class, there's simulations that are involved, and there is interdisciplinary training taking place, as opposed to the other case where sometimes training takes place, you know, within discipline only. Here the data collection involves a debriefing, as opposed to the other case where there was a form filled out, but there was no actual debriefing.

Again, it's all a function of what your system can afford, and what your system can do to implement the rapid response system. We were trying to show that there is flexibility, that it does not have to be the, you know, the well conceived model that is just the three members of the rapid response team.

Okay. In the module itself we also go to great lengths to provide exercises. One of the things that we wanted to focus on was opportunities to provide individuals - to identify what their structure looks like, and to really think about the four components, and answer some questions and think about, so if you could draw a picture of your rapid response then what would it look like, and how does it - how is it implemented in your facility.

This really is something that in field testing was a very popular exercise. Specifically the reason it was popular was that many people even within a single healthcare system were given a chance to see how they varied, how they changed from one hospital to another.

I can think of an example for Mayo when we field tested this, and there were individuals from one facility at Mayo, and individuals from another. There were differences in how training took place for the rapid response teams, or for the rapid response system members I should say, not rapid response teams. It was clear that this was something that was enjoyable because it fostered that cross pollination if you will, or that cross fertilization.

Okay. Part of this exercise also focuses on identifying what the common challenges are facing the rapid response system in its current implementation.

Again, this was a very popular exercise in that many individuals also focused on what the common challenges are. This is something that is very galvanizing during - or was very galvanizing during field testing because many of the common challenges, despite the type of implementation or the differences in implementation were exhibited across all different groups.

This was something that was galvanizing, and really led to some of the very similar types of things that happened with the SWOT analyses when you partake in the master training workshop.

Now the next phase of the module itself focuses specifically on prescribing a TeamSTEPPS tool that might be needed for the phases of execution. When we conducted our literature review and when we conducted our background research, one of the things that became very apparent to us was that there are phases of execution for a rapid response system.

You'll note that we focus specifically on five phases of execution. The first one focuses on detection which is what is required before one can activate, then activation itself, followed by response, assessment, and stabilization, and then disposition and evaluation. And it's cyclical, so you have one call, and if you can imagine, it starts with detection and moves to the activation. There's response assessment and stabilization, disposition, either discharged and put back or left on the floor, or taken to an intensive care unit, and then evaluation which feeds future detection, activation, and so on and so forth.

Let's see here. Gonna jump forward for a second. Nikki, I'm gonna ask if you could speak to the fact that these phases of execution are similar to what you've seen as a rapid response coordinator, that this is something that you've seen in practice often. Is this something that you think is common across all rapid response systems?

Nikki Schiebel: You know, from the other centers that I've interacted with, I think yeah. I think safely you can say that at some level each of these points in the care of the patient occurs. I'd say the most variation has to do with the evaluation end of it. And the degree to which different centers are assessing and evaluating their programs.

Alex Alonso: Okay.

Nikki Schiebel: But otherwise the other four phases definitely are always occurring.

Alex Alonso: Okay, thanks Nikki. So if you see here, what we do is we really try to target the phase, each individual phase. You'll see again that throughout the process what we do is we chunk the different tools that would be used in the video vignette from the opportunity of one vignette. You'll see for example, if you look to the left hand side you'll see what the detection phase requires. It says that the activators see signs of acute deterioration before actual deterioration. What is it that the phase called for?

Then we move over to the center and we see that really what this calls for, if we're thinking in terms of teamwork competencies what we're thinking about is situation monitoring, if we think about the triangle, the team skills triangle. What are the tools that we use specifically to foster situation monitoring, or to do situation monitoring? Well here we contextualize it and prescribe the step assessment and a huddle. A huddle will help you kind of conduct the situation monitoring.

Now if you think about the step assessment specifically, you'll think that it points to the fact that you're really looking at the status of the patient. When we're thinking about rapid response systems, we're talking about using the criteria set by your institution for detection. The ultimate goal here is really to answer the question is it time to activate the rapid response system, do we move into the next phase.

We also talk about where detection can occur, and how detection occurs in general. Here you'll note that we move into RRS activation and talk really about what the appropriate communication tools and strategies are for this particular juncture or this transition in care if you will. Clearly we prescribe the SBAR tool as it sets up a very quick and neat dialog for sharing information, and one that has been used countless times for transitions in care, especially expedient ones.

For response assessment and stabilization, what we bring you is really again, more background on what is needed for this particular phase, and who is acting in the phase, as well as what team skills are really needed here. This is really the phase that calls for the largest set of teamwork skills, because it calls for the proper coordination of a couple teams, and interaction between a couple teams, that being the activators and the responder team, as well as within the responder team making sure that there is appropriate leadership and information exchange, situation monitoring, support like task assistance and conflict resolution, as well as communication, and really having an understanding of that intra-team knowledge that you need.

So for example we prescribe quite a few tools here, but brief, huddle, check-back, the call out for communication, and for mutual support task assistance and CUS. We also talk about some different problem solving skills that are needed for this, and specifically using the huddle to do some problem solving, and setting forth a skill set for this. Or not a skill set, but rather a - how the active - the response assessment and stabilization should occur. We review some of the skills and discuss how they are contextualized for the rapid response system.

Then we talk about patient disposition. We provide some background as far as the communication tools and strategies that are really needed here, noting full well that you can focus on hand off checklists, especially since this disposition is not always as expedient as the transition in care from activator to responders. You can focus on SBARs as well to keep it consistent, but you can also focus on the I PASS the BATON protocol.

Let's see here. Here we provide some actual examples of how it would be used, and what the tool is. Finally we get into evaluation, and really thinking about what tools are really most effective for evaluation. When we think about these, we're talking about debriefs, as would be expected from the TeamSTEPPS curriculum, the core curriculum. We also add a few things that are really more important from a quality improvement and policy administration perspective, which includes sense making.

So for those of you who are familiar with the work of Jim Battles, who is one of the title sponsors, or one of the sponsors for the work involving TeamSTEPPS, his research has really focused over the years on sense-making in general. Sense-making is a larger view process that really focuses on how do I change practice within the overall system as it relates to a pattern or trend that keeps coming up.

One example that we use for sense making is one that Nikki speaks to often. I'm gonna let her tell the story about how some sense-making was implemented at Mayo, even though they weren’t actually calling it sense-making. Specifically, how it changed the practice, or the equipment that was used during rapid response calls by respiratory therapists. Nikki do you want to speak to that?

Nikki Schiebel: Well we've had boy, all kinds of examples now, so I'm trying to madly think what the respiratory therapy example was.

Alex Alonso: Well there was a specific airway tool that was being used that was leading to error, and the inability to set up an airway for numerous folks when necessary. One of the things that you talked about when you were referring to sense making in teaching this was that you kept noticing a lag in the amount of time that was required to set up someone's airway.

Nikki Schiebel: Oh for the suction. Yeah. We noticed within the first few months of setting up this program that we got multiple QI feedback forms from mostly the respiratory therapists, but also from some of the nurses that, you know, suction was an issue, suction was an issue. We started interviewing some of the teams, and kind of asked them well what was the issue, and drilled down on it.

Most of the time what we found is that the portable suctions that we had were hopelessly useless. Then the ones that they had on the floor, although they'd work, frequently they'd be in pieces and the team would have to be trying to put them together in the middle of a critical event. So we had these multiple airway issues with patients vomiting and no suction available. So we responded as a system by number one, changing out our portable suctions to ones that actually were effective, and, you know, easier to use.

The second was we had nursing competencies throughout the whole institutions where the nurses on the floors were all trained in how to maintain their suction machines, but also how to put them together in a crisis. We haven’t had complaints since those two things were implemented. So that's an example of one of the many kind of system fixes we put into place as a result of having this QI administrative arm that was highly functional.

Alex Alonso: Great. Okay, so now I'm gonna move forward just a bit and talk a little bit about what else this module consists of. One of the things that this module also consists of is - we talked about the opportunity lost, now we - the second example that folks will see and kind of do before they begin their practice is - what they'll look at is the opportunity one and how the scenario or the video vignette, which is about three minutes long, is different when teamwork skills, or teamwork tools and strategies are used to overcome certain obstacles.

The final exercise that goes into this specific module is identifying what the specific tools and strategies are that should be used during a phase. We provide folks with five scenarios, and there are five vignettes that folks will read. Then we ask them as a team to come up with what are the specific tools and strategies that would be used for each of the five phases to address the specific scenario or vignette that they read.

Okay. At this point I want to stop and let questions come through, because I know I've been talking for quite a while. Cori let me know if you have any questions.

Cori White: All right. Again, if you have a question and you're connected through Live Meeting today we ask that you do ask the question through Live Meeting. There's a Q&A tab at the top of your screen which will open a box where you can type in a question. We ask that if you have a question and you have access to Live Meeting that you type in the full question as we're unable to accommodate just raising your hand. So you have to make sure you actually get the text in there.

Again, as the operator said before, to register for a question on the phone, please press 1 and then 4, and you will be in line for a question. All right. So the first question that we have here is, "Has the standard expected response time been determined through your research for the responders to arrive?"

Alex Alonso: When our team was doing our background research we worked closely with Delmarva Foundation, who put together the rapid response team collaborative for the IHI group. They had suggested in their review of the research that the appropriate time, or a standard of response time was approximately four 1/2 to 15 minutes, that window there. I can't recall the exact number, or if that has changed over time. But certainly that's the number that was reported in that collaborative and came out of their research back in 2008.

Cori White: Okay. The next question is, "How can we get the RRS module?"

Alex Alonso: This is an excellent question. You'll note that AHRQ is actually mailing these out once requested. You can go to the AHRQ clearinghouse web site and order them. They are free of charge if I'm not mistaken, but I could be wrong about that. You can also get them on the DoD side. The DoD side Web site has a link that I will make sure that Cori sends out to everyone today. What it focuses on is actually providing all the TeamSTEPPS modules, or making them publicly available on the Web site, so you can get them from that Web site as well.

Cori White: All right. The next question is, "What time allotment works best for the teaching of this module? For example, how many hours?"

Alex Alonso: I'm going to speak to that next. So that's a good question, but I will speak to that later on, because we field tested that in a couple different ways.

Cori White: Okay. The next - oh that's the same question, so that's a hot question. All right, the next one is, "Could you go back to the screen that shows the barriers?"

Alex Alonso: Yes.

Nikki Schiebel: I was gonna make a quick comment about the time. My answer to that question is always it depends. It depends on who you're training, and some of it depends on how much time that the other people who control people's time will give you. A lot of times we're forced to do training in shorter periods of time than we'd like, simply because of the logistics and reality of the world.

Cori White: Okay. It looks like we're back to the barriers slide, so I will address another question while you guys have a chance to look at this. This question asks if you're able to print the slides after the program. If you download them through the handouts tab at the top of your Live Meeting, at the top right corner, it looks like three little pieces of paper that will provide you with two different PDF versions of the slides. If you download those to your computer, you should be able to print them. If you are unable to download them please send us an email at teamsteppswebinars@air.org, and we'll provide those PDFs so that you should be able to print them.

Okay. So the next question we have is, "Who reviews the feedback from the RRT calls? Are they consistent teams?"

Alex Alonso: The implementation varies, and our research showed that the actual - how that was done varied from location to location. The recommendation according to the research was really that it is the RRS coordinator, and a rotating team, or a team of RRS responders, so that the evaluation was - had some consistency, but did not have to be completely tied to staff, or one group of staff.

Cori White: All right. The next question is, "Can you please discuss how the teamwork attitudes questionnaire has been used?"

Alex Alonso: In the context of the rapid response system module it has not been used, other than for the evaluation, or the usability evaluation, the field testing that we did. But it was certainly not the T-TAQ or the more current version that was just released on the TeamSTEPPS Web site.

Cori White: Okay. The next question we have, and the last one unless people are still typing them in is, "Are there any suggested strategies for backup personnel or prioritization plan when the RRT receives multiple calls at one time?"

Alex Alonso: Again, this was one case where we didn’t see a lot of consistency across the board. I'm going to let Nikki discuss how she being an RRS coordinator has dealt with this or seen this in practice at Mayo.

Nikki Schiebel: It's interesting because our approach to this varies depending on the hospital site involved, and kind of what the staffing is in each hospital. At our main hospital it has almost 900, almost 1,000 beds. We have a pretty robust ICU system, so what happens with the second call is the nursing supervisor in the medical ICU basically identifies a second team, usually made up of her. We have 24 hour coverage by consultants. So whoever is the consultant on in the ICU will go and then they'll identify a respiratory therapist, usually from one of the other ICUs to go.

It's kind of an on the fly nursing coordinator that puts it together, but it's somebody who has situational awareness of what staffing is, and who they can grab. Now in the other hospital where they don’t have that kind of robust staffing, basically what they'll do is it'll vary almost depending on at what point in the call they are. If they're already at the other call when a second one comes in, based on that initial call, and the stability of that patient, they'll either send one or two of the members that are at the initial team to the second call, or they will activate our full code team for the second call if the first patient's already fairly sick.

So, you know, I think the answer to that is every facility will have to look at what their resources are, and identify who the best person is at any one given point in time to have the situational awareness to know how to organize a second team. I also know of facilities that have a formal pre-existing description of who's gonna go. We haven’t taken that approach, and we've found ours has worked fairly well actually.

Usually - interestingly enough, our response times to the second call, the average as well as the range of the times is shorter. I haven’t quite been able to explain or figure that one out. But our average response times here are around six to seven minutes at our bigger hospital, just because it's physically bigger, and about four to five minutes at the smaller site. Whereas our second call responses average about a minute shorter, and the ranges are shorter too. So I can't explain that.

Alex Alonso: Okay.

Cori White: Okay. The next question we have is, "How do you sustain competence after initial training?"

Alex Alonso: This is something that has varied in the research. However, one of the things that's proposed for this particular module is using exercises such as the situational exercises that are provided here with the vignettes. There are a greater number of vignettes that are provided with this tool kit, as well as we have a couple different suggestions, the first of which would involve obviously conducting some form of simulation for a rapid response call, and practicing that and having the tools practiced.

The other type of sustainment that occurs is really using the debrief and using an appropriate debrief checklist, as well as a - short quizzes. We have an example quiz that we created when we were conducting the evaluation of this particular module, or the prototype module.

Cori White: Okay. The next question says, "Did any of the field testing sites test the family and patient activation component of the RRS?"

Alex Alonso: Okay. Unfortunately for the field tests we really did not test the activation component using family members. It was not something that we were really targeting, because the goal was really to make sure that the module was working and building learning for the participants. The participants in this case were the healthcare providers and not necessarily the families themselves.

Cori White: Okay. The next question says, "When the RRT debriefs, is there a debrief form used? If so, where is that documentation filed and maintained?"

Alex Alonso: I don’t know that this is something that we can speak to specifically for the implementation. I can tell you what the module espouses in that there should be a central home for this, and that it should be the quality improvement arm that does this and stores the information.

With the debrief there's a couple different strategies that we've seen that include the high end, which is using video debrief, and a 100 point checklist to make sure that specific teamwork did take place when it was supposed to take place, and that includes trigger events that would trigger teamwork, as well as some lower end technology that would include a debrief checklist that hits five or six major questions and identifies - or provides opportunity for self evaluation for each of the members of the responder team and the rapid response system.

Cori White: Okay. This next question says, "Do you have dedicated staff?"

Alex Alonso: That question is for Nikki, so I'm going to let her answer that one.

Nikki Schiebel: Now the answer to that depends on which arm you're talking about. We have dedicated staff for the responders. I'm assuming this is probably geared towards more the administration and QI, and the answer is yes. We have a full-time FDE quality officer whose only job basically is to follow up on both our rapid response team and our code team calls, to organize our planning coordinating group meetings, and to work with myself and two other co-medical directors, basically to give the feedback to the various team members.

And in addition to that we have a facilitator who's part-time working in the ICU, who's an RRT nurse, who helps us with some of the actual practical aspects of implementing new processes. For example, with the suction machines, coordinating that and identifying that problem. We've implemented some glucose monitoring by the team itself. We implemented a rapid transfusion protocol for our bleeding patients. These kinds of things. So that person helps coordinate the practice end of it.

We have managed to lobby for significant resources to oversee our system.

Cori White: Okay. Nikki, this person actually has clarified their question a little. Now it says, "Do team members - responders - have other responsibilities? Or are they dedicated to the RRT?"

Nikki Schiebel: It depends on the time of day. During the day shift when there's the biggest volumes of flow in and out of the ICU we have a dedicated fellow. And the nurse that covers the RRT pager has limited other duties within the ICU. But on the off hours, everyone's got other coverage within. At the one site it's all within the medical ICU. The nurse, the respiratory therapist, and the physician come out of the one ICU, the medical ICU. This is at our large hospital, it has six or seven different ICUs.

At the smaller site where there's just one ICU, again the whole team comes out of that ICU. But they do have other responsibilities, although they are less, because of the RRT. Like for instance at our smaller hospital we were able to lobby for a third respiratory therapist to staff the hospital, in order to help cover the RRT. So before when the hospital was functioning with just two, with the advent of the RRT they got a third therapist.

Alex Alonso: Okay.

Cori White: All right, thank you. The last question we have through Live Meeting right now before we go to the phone is, "Has there been a clearly defined benchmark for the number of RRT calls per month per 1,000 discharge days?"

Alex Alonso: I can honestly say that I don’t know the research well enough at this point to see if that benchmark has been established or changed. I know that it varies. I am familiar with several case studies that have focused specifically on what the number of calls are for larger facilities. It varies so much from facility to facility that it's hard to get a beat on what the ideal benchmark would be without knowing specifically what your facility looks like, or what a comparable facility looks like.

Nikki Schiebel: I think to answer that question, probably the best sub-study that was done, and it was done on the merit data in Australia, they looked at that and were able to show that there was a relationship between the calls per thousand admissions I think they looked at, and the cardiopulmonary arrest rates.

Alex Alonso: Yeah.

Nikki Schiebel: Then there's some other information that's out there that suggests there is some sort of relationship. But, again as Alex says, I don’t know that we can necessarily extrapolate that data from other countries and other systems into how things work here exactly.

Cori White: Okay. Operator do we have any questions on the phone?

Operator: Ladies and gentlemen, as a reminder, if you'd like to register a question please press the 1 followed by the 4 on your telephone.

Cori White: Okay, thank you. Alex it looks like we can move on.

Alex Alonso: Okay. At this point I want to talk a little bit about the field testing that took place. We developed these prototype materials, and before they went live or were approved by AHRQ they wanted to field test them. We designed a field test that was really geared towards answering a couple questions. First and foremost, can we demonstrate that folks who participate in the field test like or react positively to the materials, and gain some knowledge from the materials themselves, and can demonstrate some learning, as well as what if anything could be improved from the field testing.

The other piece that we wanted to focus on was how are - how is this going to be trained, and how does it vary depending upon the types of people, or the types of expertise in teamwork that the healthcare providers who participated possessed. One of the things that we really, really looked towards were what are the logistics, how is this information provided.

We tested it in three conditions. We tested it in terms of time, such that we provided varying levels of TeamSTEPPS background information. That included going with essentials, going with fundamentals, or the full course of TeamSTEPPS prior to providing the rapid response systems, and then going with just a quick walk through the pocket guide that lasted no more than 30 minutes.

We tested it with mixed groups, so each group that participated consisted of about 30 participants, or 30 to 35 participants. They were trained by a team of physicians and nurses. You'll note that for two of the field test sites the physician who did the training was Nikki. So she is actually the world's first TeamSTEPPS RRS master trainer.

This group of 30 to 35 training participants consisted of half individuals who were novices in rapid response and teamwork in rapid response, and the other half was individuals who were not novices, or more expert and had seen some team training in the past, or seen some rapid response systems training in the past. The basic agenda was that we provide TeamSTEPPS basics if planned, some pre-measures, some TeamSTEPPS RRS, some opportunity to practice, a post-measurement session, and then usability focus groups. Okay?

What we walked away with was specifically that there were minor changes that could be made to the tools and strategies as they were described in the the rapid response systems module. We identified that folks really wanted more targeted contextualization, so when should I use it? What should I use? How should I use it if I'm a responder? How should I use it if I'm an activator?

A tertiary focus was that we added a lot more information about the effectiveness of rapid response systems, and the research and the value of teamwork, as well as reasons to really buy into this. One of the things that you did not see here, because I glanced over the overview was that there are a good ten slides that start off the module focusing really on what is the value of the rapid response system?

Why is it that it should be implemented? What does the One Million Lives Campaign call for? What is it that the joint commission really calls for with rapid response systems? What is the value of teamwork? Why should teamwork be used? What do recent meta analyses by (unintelligible) and colleagues really call for and demonstrate as the value of teamwork and team training?

The overall or overarching message that came about from the field test was these. First for novice teamwork RRS staff we really saw a 67% gain in knowing when to use the appropriate strategies. To give you an idea of how we assess this, we developed a pre and a post situational judgment test that consisted of eight items each. Each of those provides a situation where the practitioner or the provider is asked to indicate what the best strategy or tool, or combination of strategies and tools are to address this.

The goal here is there's not really a wrong or right answer, but we compare them - their answers to an expert panel's answers, or what an expert panel believes to be the right answer for handling that situation, knowing full well that there could be two right answers, or a best and a worst strategy. What we asked folks to do was really indicate for us what the best strategy was from a choice of four response options, and then what the worst was.

The learning that occurred from the pre to the post measurement was incredible for novices, or folks who had not really participated in teamwork training. There was a 67% gain in understanding when they should apply specific skills, what the skills were. Even if they weren’t applying the ideal choice or the expert one, there was a great deal of agreement, or a larger degree of agreement following the assessment, or following the actual training itself.

For expert teamwork RRS staff we noticed about a 32% gain in knowledge of when to use appropriate tools and strategies. Now these are just the learning results. So this is level three criteria. As far as actual knowledge of teamwork there was another assessment that we provided using some learning benchmarks, and there were clear gains in those. Those were to be expected given that some folks had not actually seen TeamSTEPPS tools or TeamSTEPPS strategies before.

You might also see that the reactions to the course themselves were very positive. Folks really felt like this was a good way to go, and really appreciated the notion that we would prescribe or contextualize for rapid response systems.

Let's see here. At this point what I'm gonna do is I'm gonna glance over this perspective here and jump to any questions that we might have. I see that we have one question Cori.

Cori White: Yes. This question says, "Is the pre and post evaluation tool for staff training available?"

Alex Alonso: It is not available as part of the module, only because it is a tool that was validated as part of the field testing, or was begun for validation as part of the field testing. I would be happy to provide an example of what it looked like. My one concern is - keep in mind that there is still normative data that needs to be added to the use of this tool.

Cori White: All right. Again a reminder that if you have a question please enter it through the Q&A tab at the top of your Live Meeting screen. Or if you're with us only on the phone you may press 1 4. The other thing that I've done in the Q&A tab is provided the link to the DoD Patient Safety Web site, where the RRS module can be located. If you go to the Q&A menu at the top of your screen, under the Q&A tab there should - you should see an answer now that I've put up the link. We can also bring that up for people later by email if they need or Alex, if we want to read it out we can do that too.

All right, so we have another few questions coming in. This question says, "For the RRS module effectiveness, please explain how the increase on the pre post tool is a level three change and not level two. Also please describe the expert panel used."

Alex Alonso: Okay. So one of the things that - and this is a great question actually. The reason that it's considered a level three - and this is a gray area that exists between level two and level three - is that you're asking someone to apply their knowledge to a specific situation, and so it takes on, am I going to apply the appropriate behavior? Will I do the appropriate behavior in paper only, okay? In paper only for this specific situational judgment. It's not to say that it isn’t like the learning, indicating that there is - I have new knowledge, I have a new level of understanding.

So it is a gray area. I agree with your question. But typically, situational judgment tests lean more towards the level three, which would be an indication of behavior, meaning I'm indicating that my behavior for this would be this. Now when you ask about the expert panel, what we're referring to is again, that expert panel that we worked with in the past that served as the strategic group. We took a subset of them, consisted of about eight folks, and they provided, you know, in kind contributions, having them identify what they felt were the best strategies for these.

What most of them did, and a good number of them did actually were provide critical incidents, or examples of how team functioning varies in rapid response systems functioning, and identified what appropriate strategies could be used to overcome those.

We used those critical incidents that they had experienced, that were taken from their experiences, and used them to develop items that were multiple choice items that really targeted what behavior they would use if given the opportunity to address the situation, for that same critical incident.

Cori White: Okay. The next question regarding field testing says, "Can you share some of the pre post measures even though they're not fully validated?"

Alex Alonso: I can share an example of them, yes. I can't do it on the software itself, but what I will ask you to do is to contact Cori, and I'll be happy to share a sample one, a very early version one. Yes.

Cori White: Again you can email teamsteppswebinars@air.org with any questions relating to Webinars, or requests that stem from Webinars. Our next question is, "Can you clarify, if you said there was more than one group of 35 participants? And did all of the groups get exactly the same training? Or did it vary?

Alex Alonso: So that is a great question. I know I kind of ran through that in the interest of time. But there were three groups of 30 to 35. Specifically what we focused on was providing them with some TeamSTEPPS background, they didn’t all receive the same background. Some of them actually received essentials only, so that was a four hour course. Some of them actually received just a walk-through of the pocket guide, and then the RRS module, which really took about 2 1/2 hours.

The essentials course was one that took four hours, and it was walking through the essentials, and then about an hour and a half of the RRS module course itself, or the RRS module itself. Then the last one took eight hours, and that was the full TeamSTEPPS curriculum in about seven hours, followed by the 1 1/2 hour TeamSTEPPS RRS module itself.

Typically it's - the question that was asked earlier was which is the recommended or best strategy for training. And what we found is for a mixed group it was really the middle, it was the four hour one where you provided essentials with the TeamSTEPPS RRS module.

Nikki Schiebel: But having said that...

Alex Alonso: It varies.

Nikki Schiebel: ...Alex I'd say that if you can't get four hours, my experience is you can get some pretty good results with 1 1/2 to 2, not having the outcome measures maybe that you have. But just, something's better than nothing I guess is what I'm saying.

Alex Alonso: Yep.

Cori White: All right. The next question says, "Will or is the data you described in the process of being published or submitted for publication?"

Alex Alonso: Yes. We have a manuscript that is in the works. Actually from this project we have two manuscripts that are in the works, one that deals specifically with the essential competencies for RRS, and another that deals with detailing the study themselves. So yes, they are in the works. One is completed and ready to be submitted, and another one is in process.

Cori White: A reminder again that we cannot accommodate questions where you just raise your hand. We need you to type in the actual text of the question in Live Meeting. Or if you're on the phone you can press 1 then 4 for a question. Operator do we have any questions on the phone at this time?

Operator: Ma'am, there are no questions at this time.

Cori White: All right, thank you.

Alex Alonso: Okay. Before we start to wind down the actual Webinar, what I want to do is I want to ask Nikki to speak to a couple questions that we have from an RRS coordinator's perspective, and her evaluation of this module or tool kit, given that she's been a chief contributor to it. Specifically what I'd like her to speak to is how this module transitions from the notion of a rapid response team to a larger system perspective. So Nikki, if you could speak to that, where you see the value in that as a coordinator or a rapid response system we would greatly appreciate that.

Nikki Schiebel: Well, I think that the biggest contribution to our training that this module has had is to move out of the paradigm of thinking about oh this is all about the team, and training the team, into a much larger arena of no, the rapid response team is part of a system, which is part of a culture change, and it's a culture change of teamwork for everybody. So it kind of builds that bridge between the rapid response team training we were doing, and an institutional level interest and approach to an overall team training for the whole institution, and a team orientation.

You take the specifics that you're training the team, but then you start to focus when you train that team on the importance of them as being the ambassadors for not only the rapid response system, but teamwork in general at the institution. Then when we go and train the activators now, we're starting to be able to focus more on not just when do you call the team, but what is teamwork about, and some of the basic TeamSTEPPS skills.

That's been a big win for us. Probably the biggest thing that this has helped me to do is sell to our leaderships the fact that it's not just about training the team. We need, and we have to have resourced an administration QI arm that can give the feedback, and continue to work on underlying issues we have, and everybody has with reluctance to call for help, and continuing case reports of failure to rescue when we review our mortality data that there still are missed opportunities related to lack of a team orientation within healthcare.

We've used the slides from this module for presentations at high level leadership to maintain and sustain our support of the system. Because initially I think what was thought when we rolled the RRT out is we'd get these resources for a year or two and then the thing would run itself. We've been able to convince people that no that's not true. You need the ongoing QI administration arm just as much as you need the three person team to respond.

Cori White: Thanks. This next question says, "I want to conduct research on teamwork among RRT and RRS. Can you recommend who I should contact in association with TeamSTEPPS?"

Alex Alonso: My recommendation would be that you can contact anyone on the TeamSTEPPS team. But I would first go with David Baker. And his email address is dbaker@air.org.

Cori White: All right. This next question says, "What hospital positions are typical RRS coordinators?"

Alex Alonso: We have seen that vary widely. The majority of hospitals in the research that we did focused their coordinator positions for charge nurses or for physicians, and specifically attendings.

Cori White: Okay. The next question says - well we have a comment first that says, "Great distillation of the material for application to a specific group." Then the question says, "Is there similar work for the coordinating team?"

Alex Alonso: I can't say that there is at the moment. Certainly it is something that is on the radar for the Department of Defense and for AHRQ. One thing that might come from this comment in particular would be something that would be a further contextualization for the coordinating team, part of the system.

Cori White: All right. The next question says, "When you say across the institution, do you also mean all departments, or only clinical?"

Alex Alonso: I think that's targeted for Nikki.

Nikki Schiebel: Yeah, I might need just a little bit of clarification on that.

Cori White: Oops, clarification popped in.

Alex Alonso: Okay, there we go.

Cori White: It said, "Our administration feels this is only for clinical staff. My thought process is teamwork is across the hospital."

Alex Alonso: Nikki I'm going to let you respond too. But what I would say is that we think of this, and TeamSTEPPS in general really, as geared for all staff, not just clinical staff. The most successful places where TeamSTEPPS has been most successful are where TeamSTEPPS was provided in some form to all members of the staff, not just clinical staff.

Cori White: Okay. The next question we have is, "Is there a suggested list of qualifications for RNs who are members of a dedicated RRT outside of ICU trained?"

Alex Alonso: There is some research that exists from the Delmarva Foundation rapid response systems collaborative that occurred for the Institute for Healthcare Improvement. I actually have something that would be able to address this question, but I do not know it off the top of my head. Again, it is suggested, it is not very well defined or very well specified for instance. One of the things that we've done here in the past is develop a specification for the necessary qualifications for TeamSTEPPS master trainers. This is something that exists, but I think it could be further specified. Cori?

Cori White: That's the last question we have through Live Meeting for right now. Again, you can continue to enter questions whenever you have them, you don’t need to wait for a questions slide. Operator, do we have any questions on the phone?

Operator: Ma'am there are no questions at this time.

Cori: All right, thank you.

Alex Alonso: Okay Cori, what I'm going ask you to do is run our poll.

Cori White: All right. As I mentioned at the start of the Webinar, we have two quick poll questions today. These are just to let us know how we're doing, the feedback from you is very helpful to us. The first question is “How useful was this information provided here to you?” If you're in a room that's a shared conference room, you'll have to discuss with your colleagues who is going to get to provide an answer.

If you'd like to answer these questions and you're only with us on the phone, you're more than welcome to email us. We're always happy to receive feedback. It looks like responses are stabilizing a bit, so I'll close this poll and show you the results. People always like to see the results. It looks like for the most part people found this pretty useful.

The next question we have is ”Would you recommend these Webinars to others?” Again, this just gives us an idea of how we're doing. We always like to know. So we'll just give you a couple seconds to get in an answer. It looks like the answers are rolling in. All right, those also appear to have stabilized so I'll close this poll and show you the results. And actually it looks like all of you who responded would recommend our Webinars to other people, and we thank you very much for that. We really do appreciate it.

It does look like we've had another set of questions come in. We have one that says, "Are institutions required to respond to radiology departments, or outpatient areas?"

Alex Alonso: I can't speak for every institution, but I can tell you what we did when we conducted our background research. It varies. I would say that about 60% do not respond to radiology departments or outpatient areas. But I do know of 40% or larger academic centers that do actually have some of the - some of that capability and do that.

Nikki Schiebel: And we definitely do.

Alex Alonso: Yeah.

Cori White: This next question asks us to add the RAD as a poll question. I'm not quite sure I know what that means. Maybe if we get a little bit of clarification we could address that.

Alex Alonso: Okay. I still am struggling to understand, so they'd like us to add radiology as a poll question. I don’t understand how that would apply to this particular setting necessarily. But maybe if the asker can provide further clarification that would be great.

Cori White: Okay, we have another question that's come in while we're waiting for that clarification. This says, "Are instructions or directions provided to the activator of the RRS for support or management of the patient, for example, blood gasses, oxygen administration, prior to the arrival of the RRT?"

Alex Alonso: The module itself does not provide a lot of guidance in that regard. Part of the reason for that is that we want folks to really focus on how they would implement it themselves, because there is an implementation piece just like with TeamSTEPPS master training. There is a body of background research and a document that's provided with the module that focuses specifically on best practices or information resources where they could go to find in the instructions or directions for this type of question.

Cori White: All right. Again, if you have a question we prefer that you would please ask it through the Q&A tab of your Live Meeting. If you are joining us only on the phone you can press 1 then 4. Operator, have we had anybody come in through the phone yet? I'm not sure if we're going to have any phone questions today.

Operator: There are no questions at this time ma'am.

Cori White: All right, thank you.

Alex Alonso: Okay. At this time what I want to do first and foremost is thank Nikki for being with us here today. We appreciate very much you sharing your insight as an RRS coordinator, but also as somebody who contributed greatly to this - the development of this module. I also want to take time to acknowledge others, such as Michael DeVita, Peter Pronovost, Brad Winters, Robert McQuillan. So many folks who contributed to this. James Franco from Carilion Clinic, the folks over at Delmarva Foundation for helping us put this together.

We are greatly appreciative of this. We also had folks contribute from the Duke University Health system, as well as the Mayo Clinic Health System. We also had folks contribute from Tripler Army Hospital. We also had quite a few folks contribute from across the world as far as their critical incidents. So we're quite appreciative of all the help that we've been given.

Let's see here. One thing that I focus on before we move on is I have a couple of announcements, the first of which is that the next Webinar in our series will be the last Webinar in the series for a while, for the next couple months because we're moving to a new scheduling process. We will be back online, but just keep in mind that the next one will be the last one.

Now before we do that, we do want to offer you the opportunity to share the success stories. So, the second announcement here is to fill four 15 minute slots in our next Webinar, where you as a system or as a group that has implemented TeamSTEPPS provide or present information about your success story with TeamSTEPPS. It could be a small success story, it could be a large success story. All we're looking for is for four groups to present for 15 minutes a piece to provide a Sharing the Successes Webinar, okay? The only requirement is that you have not presented already in the Webinar series.

If you would like to do this, please contact me directly. If this is something that is of interest to you, please do contact me directly. My email address is aalonso@air.org. You'll also see a notice coming out on the TeamSTEPPS master trainer listserv shortly. I believe it will come out this Friday asking for individuals who might be interested in participating as facilitators for the next Webinar. As far as resources involving TeamSTEPPS, we ask that you go to the ahrq.gov/TeamSTEPPS Web site. You can gather information about TeamSTEPPS in general there.

You can also see this http://dodpatientsafety.usuhs.mil/ site. This particular site is the one where you can go to access all TeamSTEPPS modules. In fact if you use this link and after the last slash, type in “teamsteppsmodules” (http://dodpatientsafety.usuhs.mil/teamsteppsmodules), you will see all the existing modules that are available. Let's see here. Here is contact information for the entire AIR team that supports TeamSTEPPS.

The last thing I want to do is thank you all for participating here today. It was a great pleasure.

Cori White: Alex, we did have clarification on our one question. It sounds like a pretty good suggestion. Since we don’t know whether or not most RRTs respond to radiology, we could just open that up to the people that are on the Webinar. We do have a lot of people here actually as resources. So if we'd like to ask that through a poll, we can.

Alex Alonso: Go ahead. Go ahead.

Cori White: All right. So we can do that now. And this is asking whether RRTs at your organization respond to radiology or outpatient areas. We'd like to know if they respond to one or the other, or both. I'm going to show the results as they come in so that you all can see what the general feeling is.

Alex Alonso: That was a great question. Thank you for suggesting it. It seems as though the results have stabilized Cori.

Cori White: All right. Well then that's about it for today. And thank you very much for joining us.

Alex Alonso: Thank you all. 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 line.