Slide: REMINDER
David Baker: …and through the telephone line that we have set up and we can get
access to slides at the end of this for anyone who wants that. My name’s David Baker
and I’m going to be the host today. Let me give my colleague Debbie Milne two minutes
to make sure that she covers the two ways to enter this. Would that be okay Debbie?
Debbie Milne: Is there anybody else that, is there more than one person having trouble
getting into the slides. Alright, the one person?
[technical assistance edited out]
DB: Alright so why don’t we begin, in the interest of time. We have a lot of material
to cover and the like. The first thing that I’m going to ask everyone to do is if
possible please mute your phone.
Illinois: Hello, this is Illinois here. If there is someone out there could you
just mute your phone? We’re hearing a lot of noise coming from one of these participants.
DB: Right, exactly. So if we could start I’ve moved onto the first slide and this
is always the challenge with these sorts of things is always put your phone on mute
to reduce the background noise. Last time we had someone that put us on hold, not
cognizant of the fact that if you have music or something in the background if you
put us on hold everybody else will hear it. So we’ll try to move forward. Sounds
like everyone is on mute now. Is everybody hearing me clearly? Great, I’m going
to assume silence is a yes.
Slide: Agenda
So today is all about implementing TeamSTEPPS and thinking about what is involved
in that process. Basically what I’m going to do is give some introduction, to introduce
myself primarily. My name is David Baker again. I’ll tell you a little background
about me and where I’m at and what I do. I’ll give you a little bit about the actual
implementation plan for TeamSTEPPS recognizing again that TeamSTEPPS is more than
just training; it’s really about culture change. I’m going to go over some of our
own efforts here at Carilion Clinic to implement the curriculum, so that’s our case
study example. We won’t necessarily align perfectly with what the QIOs have been
tasked with under the 9th Scope of Work for using TeamSTEPPS with reducing MRSA,
but I do think it will be beneficial to thinking about guidelines, best practice
for doing this because there is a lot of ways of doing this. There is no fixed solution
for TeamSTEPPS. And along the way I’ve inserted slides to remind me remind you and
to give you an opportunity to ask questions if you want to ask questions and I know
that’s a little challenging to manage giving the remoteness of each of us but we
will try to work through that. Cori, do you want to make any other comments on the
systems and ways to ask questions? Just go over the desktop that people have?
Corinne White: Yup, I can do that. At the top of the screen where in your live meeting
program you’ll see an option for Q&A, if you click on that you can ask a question
and there’s two of us here who can answer any sort of technical questions that you
may need or what we’ll do is keep a list of those questions and when David gets
to his question slides if it hasn’t been an immediate question we’ll go ahead and
filter those for you and make sure that anything that’s repeated doesn’t make it
out twice, but we’ll go ahead and make sure all of those get answered. You’ll also
note that at the top right corner there’s a little stack of papers for handouts
and I’ve put there the slides for today’s presentation, which you can download both
in the full slides format and in a format with 3 slides per page with lines for
notes. So if you want those you’ll have them. Those will not be available online
after the webinar ends however you can e-mail me and I’m more than happy to send
them to you. Other than that I think that most of the rest of it works. There’s
also a little spot for feedback, which right now all of you should be green but
if you click on the dropdown menu you can change and kind of raise your hand or
say that stuff is going too fast and we’ll try to take that into account. Other
than that I think we should be ready to go.
DB: Okay. Well great. Thank you Cori.
Slide: David P. Baker
So the first thing that I wanted to give you is a little background about me and
why I’m here talking to you all. Some of you all from looking at the attendee list
obviously I know and met either through the national implementation program or through
some other capacity. Basically I have two roles currently. For the past ten years
I’ve worked for the American Institutes for Research which is the prime contractor
for the AHRQ’s national implementation of TeamSTEPPS. I’ve been involved with TeamSTEPPS
and all related TeamSTEPPS initiatives since the beginning when we started this
work back in 2002. Some of that early work focused on defining what teamwork was
all about in healthcare. Looking at existing team training programs we did a case
study analysis of three medical team training programs within the Department of
Defense. We have done work now and in the future you will all hear about our rapid
response system curriculum that has TeamSTEPPS imbedded into it. That’s actually
a package that will be coming out of ARHQ. A complete independent package to help
with rapid response systems and it integrates teamwork TeamSTEPPS principle throughout
rapid response kind of training. I think it is a two hour block. It has videos.
Similar to what the big package looks like. We’ve been doing work on measures and
evaluation and if anyone’s come to the Carilion Clinic for TeamSTEPPS training they’ve
heard me talk about that. Of course we now have AHRQ’s national implementation program
that we’re now involved with through the American Institutes for Research. In additional
I also hold an appointment here in Carilion. At Carilion hospital system I think
we have seven hospitals. We’re at southwest Virginia near Virginia Tech, and we
are one of the four team resource centers. Now here as the director of the health
services research institute my main job is, one of my main jobs, is supporting all
of our internal implementations of TeamSTEPPS. So I’ve been actively working with
our pediatrics PICU folks, our pharmacy folks, trauma, and labor and delivery and
we continue to expand that. We’re looking at our advance care of the elderly unit
and others who we want to get on board. I think longer term we’re really trying
to get a whole hospital implementation at what we call our mothership, which is
an 850 bed hospital here in Roanoke.
Slide: What is TeamSTEPPS Implementation?
So TeamSTEPPS implementation is a process right? It’s really for those of us who’ve
been through master training now it’s all about the 2nd day. It’s all about make
this work. TeamSTEPPS is a training, the actual tools, the strategies, the contents
of that binder are the fundamental course what we spend most of the day on is really
just part of it. It’s really more about changing culture. I mean this is really
an elaborate process to think about how to institute QI programs. I think you could
generalize a lot of what we have in here to other kinds of training type initiatives
or other quality improvement initiatives. You need to pay attention, and I’m sure
anyone who’s come here has heard me talk about this and I’m sure you’ve heard the
same thing at the other centers, but you just can’t plan and implement. Really in
your planning you need to think about the sustainment. One of the things that we
say in the training that we’ve learned from our experts in teamwork and training
in the other areas of psychology and the like is organizations get the behaviors
they value and reinforce and if you don’t prepare the environment in which TeamSTEPPS
is going to be implemented for those tools and strategies you risk a lot in terms
of it actually being able to transfer because it’s highly like that when that nurse
in the middle of the night uses SBAR for the first time and the doctor at the other
end of the phone isn’t too receptive to it it’s not gonna stick, it’s not gonna
take hold. So you really have to think through what you’re doing when you’re trying
to implement.
Slide: Phases of TeamSTEPPS
This is the main implementation slide or captures the TeamSTEPPS process for implementation
divided into its 3 phases and the first phase is all about defining needs. What
are the needs that you’re trying to address? I think it’s important that you spend
a lot of time identifying that. Now you as QIOs probably have a specific measures
and information on the system that you are contractually obligated to work with
so to speak that help you understand what some of those needs are. So that’ll be
really useful. There are other tools like the ARHQ culture survey that many institutions
are already using to help get a sense of where needs are, especially looking at
those two measures of teamwork within units and across units that can help you craft
what the needs are for the particular organizations that you’re going to work with.
But this is a critical phase. I really think this is a critical phase and you can’t
think of TeamSTEPPS as a bunch of tools, I’m going to implement them all. You have
to look at the organization and think of how you’re going to map these tools and
strategies onto those needs. The next phase then of course is planning. Figuring
out how you’re going to do this and figuring out if the organization is ready for
implementing. And I know that phase two says training and I’m going to talk today
how training can come in a variety of shapes and forms and while we train one way
through the master training program I don’t think it’s necessary to train the same
when you’re implementing in the hospital systems that you work with. And then finally,
the process which I mentioned earlier which is this whole idea “How do we make it
stick? How do we make sure the transfer environment, the job environment is ready
for the tools and strategies that we have selected and we know when there are going
to be opportunities to use them and when we use them how they’re going to be reinforced.”
Slide: Slide 7
So this slide is a very busy slide. I’m going to take a few questions in a second.
If recall from master training or if you’ve been to that or if you’re coming to
that, we have a two hour block in there about implementation planning and we’ve
designed, it’s actually Appendix H for those of you who have the TeamSTEPPS binder
and one of the folks we work with, an orthopedic surgeon, took Appendix H and turned
it into what we see as a little bit more usable set of PowerPoint slides that we’ve
been using in the master program and would be tool or a resource for you all, I
believe, when you’re working with your systems. Now this slide, as somebody must’ve
said “John can you put it all on one page for me?” And he did, but this overviews
the whole process. It’s actually a whole set of slides dedicated to each of these
ten steps and you can print them out and copy them easily. Our pharmacy has used
that to capture their whole implementation plan so they can brief it whenever they
need to brief it to somebody who is interested in what they’re doing for example.
One of the things that I want to say is that we use this not for big but we found
it extremely useful.
Slide: Implementation Timeline (Slide 6)
It’s available. If you want to get this you might send an e-mail to Cori or one
of us, and I have some of that information at the end, and we’d be happy to distribute
it to you. Recognizing that it’s a tool, it’s not going to come to you in PDF. You
can adapt it, you can use it for any of the change initiatives that you’re involved
with. For those of you who’ve come through master training we’ve also developed
a QIO kind of a version of the process where you think about how you’re going to
market and communicate the TeamSTEPPS initiatives to your hospitals as well as think
about what tools might be useful. The primary requirement, obviously being reducing
MRSA, but also some of the other patient safety items that are in that block of
the SAW for you all as well, and the QIO training because they’ve spent some time
matching tools to segments of their work requirements over and above [interference]
Slide: Questions
Okay. Are there any questions about some of the additional implementation package
or would anybody like to raise anything right now or bring it to the attention of
the group?
Slide: Before You Start
Okay. So now I want to go through some of the steps that I think are going to be
involved from the QIO perspective that round out the steps we just saw on that one-page
summary slide, and I think the implementation plan slide-set, as you just saw summarized
in that one page is great for…
[Technical difficulties with the phone system in the DC office caused the moderator
to drop out of the call. This portion of the transcript was created form a backup
recording of lower quality than the rest.]
DB: Cori?
CW: Hi.
DB: Are we back?
CW: Yeah. I think something happened to the phones here in Georgetown because Deb
and I both got disconnected. I don’t know what happened to our phones, but we had
a little glitch. But I think we’re back.
DB: Okay, we’re glad to have you back and we’ll see what happens. Alright Cori,
I’m going to continue then.
CW: Alright, I think that’ll work.
DB: Any questions before we start?
CW: We have one question, I think. [participant 1], with her hand raised in the
questions and answers. I don’t know if that’s been dealt with. There was no text
to the question.
DB: [Participant 1] do you have a question?
CW: She might not be back. We’ll just wait and maybe next time we have questions
she’ll be back.
DB: Okay, what I was saying, I’m sorry for the temporary disruption here, is the
next to slides are about walking through the implementation plan. So we’ll [inaudible]
in terms of what will benefit you as a QIO. One of the things we spent time when
working with QIOs through implementation is how [inaudible] QIO partners [inaudible]
that’s an excellent resource tool available. The other thing that we’ve done is
we’ve created a website through ARHQ which really supplants the national implementation
of TeamSTEPPS and gives you information about programs and we’re going to share
this with you briefly to give you an idea.
Slide: David’s Desktop
So this is the national implementation site and as you can see it has information
about TeamSTEPPS, it has information about delivery systems. We’ll come back to
the readiness assessment here in a couple minutes. It’s got things like the spotlight,
things like this webinar are on that site. It’s got a resource where you can post
your hospital easily on. There’s also a way to and the like.
Slide: Before You Start
DB: So that’s one resource you can certainly look at. [inaudible] is we’re creating
a leadership brief. Basically this will be about 10 slides with information on why
you would do this, what can it do after implementation, what will be learned, what
does it cost, and what is the next logical step. We’re going to post that [inaudible]
before it’s ready to go up on there, but it will be available. There are different
issues that we have [inaudible] but that’s something that’s there to use as you
go through with your system. Who’s the vice president of quality, who’s the vice
president of medical affairs [inaudible] and initial [inaudible] for the institution
that could be a tool or resource you could easily use for that.
Slide: Before You Start (00:23:50)
[there is a break in the recordings as the moderator’s phone line begins recording
again] …and the like. There’s a series of 10 to 12 questions that you can work through
under one of the tabs that says “Determining Readiness”, and basically it has questions
that you need to answer yourself about whether or not you’re ready to undertake
this particular program. It gives specific guidance in terms of a score you come
up with and what you may need to do. It’s based on the best available evidence,
so I do think it’s something; it’s more designed to be something an organization
should consider as opposed to be hard-fast rules, but it’s something you may use
yourself as you’re thinking about working with different hospitals. Do a quick assessment.
It may be something you can use as a tool when meeting with senior leaders as you’re
thinking of things for them to consider. [background conversation begins]
Slide: Step 1: Guiding Coalition, Executive Sponsor and Change Team
Lots of things to use in terms of getting a sense of whether or not the folks you’re
going to work with are ready for this journey. Somebody does not have their phone
on mute, okay. Thank you.
[edited out background conversation]
DB: Okay, so once you’ve done these initial steps I think the next step is you really
want to move into the implementation plan, which again is tab H in the subsequent
materials, or the slides that we set up which are an extracted tool from those materials.
You need to think about who is going to guide this and in TeamSTEPPS or terminology
that is the change team. So the QIO at this step I think can really help out thinking
about what and who should comprise the change team. I think the change team is the
key to a lot of the success and you really need to think about how are you going
to ensure there’s some positions on the team, how are you going to make sure that
you have people that are champions of team work, how are you going to deal with
the issue, and I think this is where some counseling could go in, about getting
the right folks in terms of people who are truly the leaders in the unit you are
working with, and that is the problem I think because you’re going to have this
designated leadership, whether that’s management, directors, CPs, whatever the structure
in the organization but you’re going to have to figure out a way to undercover who
is the folk in that unit that are the respected leadership and how do you deal with
the designated leaders and team leaders to make that transition smoothly. Finally
you need to think about what folks are going to be effective coaches, effective
communicators, and I know in some organizations they have separate coaching teams
and separate training teams that are aligned but serve different functions, but
I think you can really help your organization think about who those people are going
to be because you guys do a lot of work on the consulting side and that’s what you’re
really looking for is a good consultant.
Slide: Train the Change Team
So training the change team. Once you’ve identified the change team you need to
figure out a way to introduce them to TeamSTEPPS. Now that isn’t really covered
in the current slide or in tab H but at the end of the day if I’ve identified I
want to do something, that I have an issue related to teamwork that I think TeamSTEPPS
can help me with in terms of defining change team I need to somehow teach them about
the curriculum. And so the master training program depending on how you all are
going to structure that, you can hold your own master training for your state QIO
and change teams could be sent to you, you can work with change teams on the individual
systems or hospital level, lots of things to think about who you’re going to change.
And what we’ve done is identified our change teams and we’ve introduced them, just
the change team here at Carilion for each and every implementation, to the entire
TeamSTEPPS package. So we’ve educated them what TeamSTEPPS was about. Not the entire
unit, but just the change team. How we did this is we did it in one day just going
through the curriculum, and we didn’t just worry about the coaching or the implementation
workshop, we’re here on site with them. We can do that through a series of meetings
later. And we didn’t do any teach back like you’ve seen in the training program
because which I’ll talk about later, didn’t require any hands on teaching. So for
our pharmacy for our PICU we brought them together for a day as we were first learning
ourselves how to be good trainers for TeamSTEPPS under the national implementation
and taught them the whole curriculum. Didn’t do any coaching, didn’t do an implementation
workshop, didn’t do any teach back, just gave them all the tools and materials so
they could think about what their needs were and what they might do.
Slide: Step 2: Define the Main Problems, Challenges and Opportunities
Once we did that then we worked with the teams and the next step here once you’ve
identified the change team, and I think the step that is missing here is how are
you going to educate them, that was the previous slide, you need to meet with them
and define the main problems, challenges, and opportunities. In the case of our
PICU, and I’ll talk a little bit more about this, we looked at some of our RCAs
across the institution. You can conduct surveys. One of the tools that is ready
for you and available is the AHRQ culture survey, and I know Mai Tong on the phone
from New York Health and Hospitals that they’ve used this tool. I hope it’s okay
I’m saying it, and I hope that could be a source of information, they’ve used it
over multiple years to understand what some of their needs are in their hospitals.
We also have some other tools that are available. One is a quick and dirty measure
of whether or not people are motivated to learn and whether or not there is a belief
and the sense of worth in teamwork. If they don’t believe teamwork is important
that could be a problem in terms of longer term training. And the final thing that
we’re working on is this attitude scale which will measure attitudes about teamwork
that are specifically aligned with TeamSTEPPS. So there are other schools on the
market like Brian Sextons survey this one that we’re putting together should be
ready, again, in another month is going to be something specifically aligned with
TeamSTEPPS. You could also conduct observations of the unit of interest. There are
certainly tools and team materials to do that, but you need to think about how you’re
going to do that, training the people spanning the different shifts. One of the
things that we’ve had a lot of success with in our experience so far is doing interviews
and we’ve been doing interviews of about six to eight staff, interviews that last
about 30 to 45 minutes. We try to span all the different professional groups presented
in the unit or service. What we’re trying to do is also come with a process model
of the system and then of the unit we’re studying, and then we’re trying to understand
within that the teamwork requirements within the different blocks of the process
and what kind of variables can impact teamwork, and if anybody was interested in
this kind of thing that may be the kind of thing then that may be something we can
post longer term, but we’ve been using the interviews, you learn a lot in the interviews
to help define the needs and it’s pretty much you can knock them out in a day learn
depending on what and when and where certain tools can be implemented.
Slide: Step 3: Define Aims of TeamSTEPPS Intervention
So the next step is to then, once you’ve collected the needs data, to define the
aim. I think that you as guys are really going to be perceived as the experts in
TeamSTEPPS you need to help guide the change teams and really thinking about what
they should do and how they should do it. So in the bottom of this slide one of
the things I tried to think about is there is some hierarchy to the actual TeamSTEPPS
tools and strategies. Some tools and strategies are much easier to implement in
my opinion than others. So my TeamSTEPPS 101 is SBAR and Huddle. The reason they’re
on the easy end of the spectrum is because we know when these things should occur,
they can be defined events, and we know when the behavior is supposed to happen.
So we know when a nurse calls a physician about a patient he or she should be using
SBAR to present that information. We know that a Huddle between the pediatric and
the PICU is scheduled for 7, 3, and 7 and 12 to discuss patient flow, patient needs,
and the like. So they can be very defined events. I might put debriefing in there
too because we know when it’s supposed to happen and what that’s about. The reason
there, that makes them sustainable because we know when the opportunities for that
behavior should occur and we know to value and reinforce that. 201, or the next
level of difficulty I think gets into this assertiveness issue related to things
like CUS, I’m concerned, this is a safety problem, that’s a mechanism for asserting
a concern about the patient. It’s a little bit more ambiguous about when that behavior
is supposed to occur which makes it a little more challenging to coach, monitor,
and measure. 301, the hardest one I think, are the conflict management ones and
we are actually thinking about evolving some of the conflict management workshops,
the DESC script. How do you do that? How do you teach people to be effective with
conflict management? I would say it’s some of the more difficult, challenging sort
of tools in there. So there’s a hierarchy and when you start this sort of thing
you need to think about the hierarchy, what makes sense, what can be done, where
can I get my quick win under the Kotter’s model that this is all based on to move
this forward. The other thing I think you really need to think about and you can
guide the hospitals and systems that you are working with is really think about
who this tool, this intervention going to touch, because we spent a lot of time
in our pharmacy initially talking about introducing SBAR and what we talked about
with the change team is I said “Well you gotta be careful because we don’t have
all our physicians onboard with it yet with SBAR.” So if the physicians aren’t onboard
and the pharmacists are trying to use SBAR to talk with the doc we could run into
some problems there because the physician might not be receptive on the other end
of the phone. So you need to look at it as you’re implementing the tools, is everyone
on the same page so the behaviors will be valued and reinforced.
Slide: Step 4: Design a TeamSTEPPS Intervention
So once you’ve identified the need, once you’ve identified what you’re going to
do, you really need to think about how you’re going to do it. I mean, how are you
going to make this happen? I really think this is, again, an additional tricky part
that you can really help out with, especially as you go through more and more implementations
with different hospitals and people that you work with. The slide-sets and the modules
kind of imply that if you should really approach TeamSTEPPS that really consider
all these things, and I’m not sure I’m a big big believer in that. I think we need
to think specific tools, we need to think about a dosing application where we make
a quick win. The other thing I think you need to think about here is staff availability
and the way TeamSTEPPS is structured in the master training program we have you
as captives in Roanoke or Minnesota or Creighton and we have you for three days
and we can work with you hand in hand, but staff availability is a tough thing in
hospitals. Most positions and units are understaffed so they really need to think
about how to integrate the training or dose it a little bit further into existing
kind of meetings, lunches, and the like. So for our SBAR implementation for PICU
that I’ll talk to you about, we had a series of meetings, we didn’t really have
any formalized training where we brought everyone together and pulled down staff
time and had to pay for training. The other important and final point I want to
make here about this is that you need to recognize that these tools and strategies
require some sort of practice and feedback. So I’ve talked to a number of systems,
a number of hospitals that have tried to implement SBAR. We’re no different here.
We started it the same way and it had various levels of traction. We did it through
memorandum, we sent it out through the whole system, we’re going to start using
SBAR now and this is the new policy for Carilion. The problem with that is there
wasn’t any practice. There wasn’t any conduct to make sure the behaviors vis-à-vis,
what we really meant, what we expected people to do. So it was only when in our
pediatric environment we really spent time clearly defining it, really pulling other
resources around it and really giving an opportunity to practice those skills that
it really gained traction. So recognize that a lot of people, and this really interesting
because they know what to do but sometimes they don’t know how to do or they really
should do it. So the practice and the feedback is really the key to making a lot
of these things stick.
Slide: Questions (00:39:46)
So, questions? Does anybody want to raise their hand so to speak, and I’m sure Cori
will help me out with this, about anything I said about before you start, the change
team, the site assessment, or the intervention selection and design.
CW: We do have a question. This one is from [Participant 2]. [Participant 2] says
“I worked with some clients who liked to use SOAP, S-O-A-P, as a format tool that’s
more familiar to them rather than SBAR as another acronym to remember. Do you have
any comments on that?”
DB: Sure. I think SBAR, really what we’re interested in is the guidelines and principles
that surround SBAR and SBAR is what’s included in the curriculum. But any tools
that you can use with the organization that creates a standardized framework for
communicating that information that is acceptable to them is fine. We’re not bound
to anything in TeamSTEPPS in terms of those tools and strategies. What we see is
here is a possible set and what we want to do is advocate some guiding principles
for best practice. So I’ve seen a lot of adoptions of different tools that people
have come up with centered around a sort of QI initiative for improved teamwork.
So the Duke “I Need Clarity” cards that they’ve developed, lots of variety. We’re
thinking about here whether or not we’re going to implement CUS or create our own
variant of it as a way to assert one’s-self that we can agree upon while leveraging
some other things we’re doing so anything like that is fine. Any other questions
do we have Cori?
CW: That’s the only one I have through the system right now.
DB: And just so you know we’ve had people change, for those of you who’ve seen the
triangle, they’ve adapted the triangle for themselves. They’ve done all sorts of
things, because this is public domain other than the trademark associated with the
name, I think AHRQ and the federal government and the like truly expect customize
and do the things that they think make sense and what we would hope that is part
of a national implementation agenda is that you would ultimately share your success
stories because we’d like to capture those and pass them on to others.
Slide: Step 5: Measures
Okay, so I will continue. Step five, which is in the implementation slides again,
talks about measures, and I think this is really where, and in all these steps you
guys have a tremendous amount to offer because this is about organizational change,
quality improvement, and it’s kind of a very consultative role in people make the
right decisions and bring this all together. Measurement of course brings some additional
expertise to think about and use in this context which is of real benefit for the
system.
[edited incorrect slide changes, slide returns to Step 5: Measures]
DB: Okay, so, we’re back. I think that what you need to think about in particular
with measures is defining what you’re going to measure and be sensitive because
this is a QI intervention that those measures should focus on both process and outcomes.
So a simple example I have underneath here: the a process would be increased hand
washing, right, if that was an initiative, the outcome we’d expect to see is decrease
in MRSA rate. So you can help change team identify the best measures and design
studies. The interesting thing I found with our implementations, and I will compare
our pediatric group again with our trauma folks, is different units have their own
cultures. Our pediatrics group, their needs assessment was in part driven by their
gut. They knew they had issues to deal with in respect to communication. They wanted
to do something and they worried less about base-lining the whole thing and seeing
if it worked and all that, they just felt this was really important. The doctors
and the nurses needed standard ways to communicate. They need to focus on patient
flow issues and they just wanted to move forward. Our trauma service on the other
hand wants to do some solid base-lined measurements, they’d like to package some
research around it, they’d like to know about the effectiveness of these things
that they’re doing. So we’ve had success in both areas. Again there are no hard-fast
rules, you have to work with these individual clients and kind of spec out if you
really want to know the answers to it’s effectiveness this requires these kinds
of measures, these kinds of base-lining, collecting these kind of post-measures,
if you’d like to just move forward with a QI implementation it requires this. So
I really think you can coach people on the implications for their decisions and
what their true objectives are. And that’s really the role that I’ve provided here
and I think you will provide to your system because it is a lot of material to digest.
Slide: Step 6: Developing a Formal Implementation Plan
So, developing the formal plan, what can QIOs do at this step? I think you can document.
One of the things about the slide set that we’re going to send out is you can actually
use that as documentation like our pharmacy does. It does present an easy way if
you need to bring it back to everybody, very useful resource, because people ask
and I think the problem is on the change teams they don’t always have the time to
come up with a formal tool to help them develop their story and that’s really what
you want to be able to do at the end of the day with respect to this.
Slide: Step 7: Sustainment
Sustainment, I think this is the real challenge with this. Ultimately the system,
the unit, the organization needs to own their own intervention. So you can help
them, but this is kind of at the point where you need to begin to pull yourself
back and kind of just encourage them, because they need to own it, that’s why there’s
a change team, that’s why TeamSTEPPS is structured the way it is. So this is always
the role of the consultant right, when you need to kind of move away and not let
the client be completely dependent on you. So that’s a challenge. Now I think in
terms of your particular contractual obligations related to CMS and related to when
working for the systems, you can be the judge of what level of effort you want to
provide, but I think to really make it successful they need to own it themselves
and you’re really there to guide and give feedback about how they are doing.
Slide: Step 8: Communication
So communication, I think this gets into again if your capturing the plan you’re
going to have the ability to share the plan, and one of the things I found about
TeamSTEPPS, at least in our organization, is once one unit does it, and they don’t
have to be necessarily too far along or a successful unit with it, a bunch of units
start lining up that want it. So on the one hand I think it’s very valuable that
you be able to communicate and tell the story of the people that you’ve worked with
to other units and will help you work with other systems, but this also, when you
find committed people, people understand the benefits of this you’ll have kind of
judge and be ready for the onslaught, so to speak. One of the things we always talk
about on our end is you need to be prepared for success, because people really want
that. I have a number of organizations in our own unit that have lined up to get
it, that are waiting in the wings so to speak, that because they really want to
move forward with this initiative and they think it can benefit them.
Slide: Questions (00:48:28)
So are there any questions at this point about the final steps before we move into
the study?
CW: I don’t have any, no. I just want to make sure you have a time reminder that
we only have a half an hour left.
Slide: Slide 23
DB: Yes, I got an e-mail. I’m good.
Slide: Background (00:48:57)
So let me talk a little bit about our case study. I’ve already talked about so I’ll
probably go through it a little bit quickly. A little bit of background about Carilion:
like I already said we’re an 850 bed hospital, we have approximately 5,000 employees,
we provide health services. Carilion Roanoke Memorial Hospital, I’m just talking
about now, provides services to all of southwest Virginia. We’re a level one trauma
facility. To give you some idea about Carilion, one thing that we really stand for
is change. We have all sorts of change going on right now. We’re concurrently introducing
our electronic medical record EPIC. We are also currently developing the Carilion
Clinic, which will be a new model for developing and administering care. We’re also
in partnership with Virginia Tech beginning a school of medicine. So there’s one
thing about Carilion and our institution, particularly here at Roanoke Memorial
Hospital, we have lots of change we always kid about with TeamSTEPPS is that we
already have so much change just fitting another one in isn’t that difficult to
do. But if you went through that readiness assessment your judgment might be we
have too much change to take on another change. So again, this is working in an
environment where we have lots of organizational change going on.
Slide: Determine Readiness
In terms of readiness, you can go to that page. In addition to the system changes
that we have within Carilion, our pediatric group just moved from our community
hospital in downtown Roanoke to a new unit within Roanoke Memorial Hospital. So
in September we moved everybody from here where I’m currently sitting and where
my office is, down to our main hospital in Roanoke down to our Pediatric and Pediatric
Intensive Care units. So there’s an additional kind of merging of cultures that
went on because you’re integrating some of this staff together, and despite all
working for the same company different organizations have different styles of doing
things and the like. Also in our clinic model we’ve been hiring a lot of physicians,
a lot of new people from medical school and the like, so we have new people coming
all the time. Now, the key to this though, I think, in making this successful is
we had a lot of leadership support. So our VP of medical affairs who has been here
15 months is a quality person. He’s very in touch with these kinds of initiatives
and the importance there. Comes from Children’s Hospital, he’s a pediatric care
physician. So he works from PICU and Pediatric unit as well. Our director of nursing
has very competent leadership and had her staff on board , was able to get the physicians
onboard as well and get them involved with it early on, and we had physician representation
on the change team from the get-go.
Slide: Change Team
Like I said we had six members, two of them were physicians, we had representation
across shifts and we had representation from respiratory as well, and here when
I worked with the DON we talked about fixing up the formal and informal leadership,
and we did a good job of getting the leaders the staff perceive and the management
leaders into one functional change team that could make this happen.
Slide: Train the Change Team
We trained the change team first before we did anything about needs. We had this
big debate about what they needed to know. We felt it was really really important
that the change team had some idea of what was in that eight and a half pound binder.
And that’s the dilemma that I struggled with because I think the challenge here
is if you only focus on certain things in TeamSTEPPS right from the get-go people
are going to want to know why they aren’t getting exposed to the other materials
in there. If you focus on the whole thing it can be a bit overwhelming. So what
we decided to do is to train our change team in the entire curriculum over one day.
Fortunately for that it aligned with our master trainers getting ready to be a resource
center under the national implementation program. We covered all the fundamentals
and also trained people from our pharmacy change team at the same time so we had
multi-disciplinary teams in there, which I think is beneficial because it gives
you different perspectives on things, and we had some of our Carilion corporate
university folk that do a lot of our educational and professional development, which
helps us kind of align other things in our system.
Slide: Define the Problem
Once we completed this change team training we did everything else through periodic
meetings; that’s the implementation planning, getting ready for the coaching, anything
else that we wanted to do. So we had, our needs analysis consisted of three things:
we asked our master trainers, who is also our patient safety officer, to review
our sentinel events system-wide, and the number one cause of those sentinel events
were breakdowns in communication. I don’t think that’s any surprise to anybody based
on joint commission data and other data. We also looked at our patient satisfaction
data and one of the things we noticed is that patient satisfaction had dipped since
the move and that one of the things that was a concern in there, one of the variables,
and I’m sure that anybody some of the standard satisfaction measures there’s a variable
in there about nurse-physician teamwork was one of the things that was highlighted
in that. And the final thing we did is we got general perceptions. The change teams
sat around and figured out what the biggest need is, is communication the biggest
need? We reviewed some of the cases and everybody concurs that this is something
we wanted to focus on and none-the-less we still had concerns about how we were
going to do it. How were we going to deal with nurses who come in who aren’t necessarily
trained periodically, how are we going to deal with new residents when they come
in, and we’re going to have to deal with that problem shortly, and the like. So
we had a lot of discussion about this and thinking about our plans.
Slide: Define the Aim
It took two or three meetings just to sort out what we wanted to do and we begun
with our focus on communication and talked about kind of our past history with SBAR,
why it wasn’t working now and determined overall that this was a good place to start.
That being said though, we wanted to make it broader and we did something a little
different that TeamSTEPPS doesn’t talk about and made communication a theme for
the remainder of 2008. So it’s not just about introducing SBAR up there, and I say
up there because it’s on the 12th floor, it’s about communication in general, but
the highlight or focus point for us is starting with the SBAR. So we decided that
the theme in our pediatric groups for 2008 was improved communication. We started
with SBAR and we focus as our next tool to improve communication between PICU and
Pediatrics as Huddle. So we started with SBAR, gained a quick win, moved on to Huddle
and we made a broader focus on a communication topic, and we’re doing other things
to reinforce the focus on this like having a grand round where we’re inviting a
physician from Duke to come and give us a talk about communication in pediatrics
and some of the work that they’ve done with their TeamSTEPPS initiative.
Slide: Design the Intervention
The way we did this is we did this was with minimal training, minimal staff time
requirements. So we introduced TeamSTEPPS at a staff meeting and basically all we
did to introduce the concept is we showed the Sue Sheridan video and had a discussion
about it and then talked about the notion that this would be coming, we would be
focusing on these things, and the next thing we’d do is do some brief SBAR training.
So didn’t have a huge stand-down, didn’t teach the whole one hour communication
module, dosed a little bit more, picked apart at the slides out of TeamSTEPPS that
were useful to us, and did it through already existing meetings that occur. The
second thing we did was hold our SBAR training. Made sure the nursing and the respiratory
and everybody participated and we made them do it. We made them practice and give
feedback on the concept so they could begin to get used to using the skills. And
I think one of the big things that became apparent here is that nursing wants to
give physicians the correct information and once they understand of what the physicians
wanted it made it go very quickly and very easily. The third thing we did is we
created a bunch of reinforcers in the system. We have penguin pens, penguin pins,
we have posters, we have squeezy penguins, all sorts of things you can do in pediatrics
that work really well. But I think the key here is when we first launched SBAR the
folks up there just took an 8 1/2 x 11 piece of paper, they wrote the S, the B,
the A, and the R and created a little box for each phone and you had to fill them
out before you call, then you threw them out so we could keep track of them afterwards.
We created a useful kind of tool that embedded measurement into the system and sort
of reinforced the concepts. Once we had a successful implementation of that we moved
on to Huddle, but for Huddles we just trained the people that would Huddle, which
were the key leaders across those units. So when are you going to meet, what are
you going to talk about, what are the key concerns. And that allowed us to coordinate
patient flow better across the units.
Slide: Measures
So measures, I’ve gotta say when we met with the change team we ignored this step.
They weren’t interested in getting a baseline. Looking at the sentinel events they
thought that data was enough. However we put some little measures in the system,
right, with that notepad idea where we had people fill those out and make sure we
kept them, and that sort of reinforced you were supposed to do it if it was by each
phone. We had informal observations, kind of the change team keeping track of things
and we have some archival data now that shows that this all worked. One of the things
we noticed now after doing this for two or three months is our patient satisfaction
has come up significantly. Now is it directly related to this I can’t 100% say,
but this maybe hasn’t hurt and I need to kind of drill down the data more. We also
are in the process organizationally of implementing the ARHQ culture survey. So
one of the things we plan to do is look at the readings in our pediatrics unit for
teamwork within unit and compare that to other units that haven’t implemented or
done anything yet. The final thing for us I have on here is SERV-U which is actually
our customer service plan, but it has a lot of element of teamwork within staff.
And here at Carilion one of the nice things we can do with TeamSTEPPS is we can
align it with the SERV-U program because the SERV-U is all about teamwork among
staff at the end of the day and it counts for 35% of your performance rating, and
we also have a separate program, unfortunately it doesn’t fall under the same rubric,
but it is separate and similar to a system called PLSE, Positions Leading Service
Excellence. So we have some the things in our HR systems that align with these initiatives
that if you as a QIO know and can fit these things together for the organization
that’s fantastic. In fact one of the things that we discussed and I think would
be perfectly appropriate to do is we discussed here whether or not we wanted to
continue to use the moniker TeamSTEPPS or just continue to fit this under more of
the SERV-U program, which we already have fairly well instantiated in our staff.
Slide: Implementation Plan
So I serve the role of QIO, I captured the status on the implementation slide-set,
we have regular change team meetings, and the other thing that we’ve done here is
because we have multiple implementations, we have a quarterly cross unit team change
team meeting. So right now all of our implementations have been unit based, but
as we move forward we need to understand how those units fit together well and what
TeamSTEPPS tools and strategies we want to use to facilitate cross unit coordination
among them and we’re kind of beginning to strategize how this might fit into a wider
hospital and organization roll out, which I’m not currently aware although I know
the University of North Carolina has implemented this in a lot of their units and
are working on that as well.
Slide: Sustainment and Communication
Sustainment; we’ve got lots of trinkets, we’ve got strong of leadership, we’ve got
this grand round coming up in July, and we’re planning our next tool. So we introduced
one, had success, introduced Huddle, had success, keeping tabs on things, had a
grand round, going to introduce the next tool. So we have something rolling out
every two months to keep attention on this that are aligned with the needs of this
particular unit. In summary: customized solution, started relatively simple, had
strong leadership which I really think is key.
Slide: Summary
We really minimized training but ensured that practice contained and feedback, and
we had constant reminders in the environment about this.
Slide: Questions (01:04:43)
So are there any questions about what we did here in this particular unit at Carilion.
CW: I think that we’re set on questions. No one else has sent in a question so I
think we’re okay unless someone on the phone has a question.
[no response]
Slide: Tips for Guiding Successful Implementation
DB: Based on all that, few tips, and I think they’re fairly apparent. I think you
really gotta assess whether your organization is really ready and ready to engage,
and particularly in terms of the leadership. I think you guys can really go a long
way in helping think about the change team and I do think that’s a critical first
step, because what the organization may propose to you as a change team you may
not want and I think you’re going to have to figure out a way to clearly specify
who you want and who you need, and the trick of course is figuring out this position
engagement piece and one of the things that I think is more challenging is when
you’re dealing with physicians who are employed docs, that’s one level of engagement,
but what we’re dealing with over the next six months since moving our labor and
delivery unit, who are private docs, that engagement is going to be a little bit
more of a challenge and how you work with a private doc community in helping them
and getting them involved in different community kind of hospital implementations.
I think it’s really important to be narrow and defined in what you are trying to
do. You almost might work backwards, right. Instead of thinking what is in introducing
this training you expect these changes to occur. Start describing what changes you
expect to see or how things would look in the unit at the end of the day and think
backwards as to what do I need to do to make these changes happen. I think that’s
a really good place to start. I mean, one of the things we use in some of the work
we do and I do with systems is just, in your interviews you can ask people what
should the start doing, stop doing, and continue doing. And that can be really informative.
It’s almost like the magic wand exercise that you’ll find in the introduction of
TeamSTEPPS.
Slide: Tips for Guiding Successful Implementation (01:07:20)
Other tips, obviously one of the big discussions we’ve had and we’ve had particularly
in the master training sessions is about resistance, how to deal with resistors
and how to kind of address this factor. One of the things that we did do in our
PICU piece implementation is our director of nursing put one of the leaders on the
team who are also likely to be the most resistant and once we won this particular
person over that helped tremendously in making this effort successful. So there’s
some benefit to thinking about how to get resistors involved, how to keep them or
put them in part of the change team, but again it’s a judgment exercise that I think
given your years of experience, and what you do in kind of consulting with these
organizations is you’ll very be able to help the organization think about what they
need to do. Okay, I think the other thing on that slide that’s really important
is you need to celebrate your successes. I mean, we started small, we celebrated
our wins, we had good buy-in because we were able to get the first one to work
Slide: Do you have any final questions?
and people saw value to it and we highlighted the success of that, and so it’s highlighted
within the organization and it’s been something that the pediatric group is proud
of. They’re kind of leading the way on some of this and I think that we really want
to do here at Carilion and is a really good opportunity for them. They’re hosting
this grand round which there’ll be a lot of interest in from kind of the community
and organizational perspective. So all these things have really brought attention
to them and they really value that here in our particular organization. Anymore
questions as I kind of wind this up, and I’ve tried to leave a little bit of time
if you questions.
CW: We do have one. This one is from [Participant 3]. What is the anticipated timeline
for completion of this process at this organization?
DB: Well, I mean, complete introduction? I don’t know. We’re kind of pecking away
at this unit by unit. Those are the implementation that I’m familiar with. They’ve
been unit or service based. As we hit more and more units we’re beginning to think
more broadly as to what does that mean for our hospital and how to make all those
pieces fit together. And we’ve finally been having some discussions and thinking,
and maybe we’ll have some guidance in the near future which would be helpful to
all of you in terms of a size standard for thinking about whole hospital implementations
versus unit or service line implementations. So we have, for example, in the Carilion
health system, two critical access hospitals. And we believe in those hospitals,
which we’re going to work with soon, we could move to a more whole hospital model
in terms of these are the tools you’d use across this 25 bed system or organization.
But where that cutoff is for this sort of whole system approach and aligning everything
at once and kind of the dosing model that we’ve taken, I don’t know at this point.
I think it’s an interesting question. Is it a 100 bed, is a 200 bed? Is it smaller
than that? But we think that you might consider as you move across your implementations
and working with different size systems the issue of size and what you could do
in various sizes and report back to us. And two: I think there’s a lot of benefit
to begin to have cross implementation meetings somehow. One: It allows others to
learn from each other, and two: it begins to allow you to think about how all the
pieces fit together by everybody knowing which tools are being implemented, and
different tools in my opinion may be better for different units, so SBAR might be
best good in the ICUs but maybe briefing is really god for ER teams, rapid response
teams, and the like, you can have a lot of success there. Sorry I can’t give a specific
answer to that but we continue to move forward with our progress. Any other question?
CW: None here.
DB: Okay, so if you have questions don’t hesitate to ask. We have our e-mails up
here, we’re always interested in helping you all out. One of the goals of being
part of the national implementation program is for us to help you sustain it to
make it work. We have an 800 number for those of you who come through Carilion.
We, I have said we want to help the QIOs as you begin to think about working with
your hospitals. We would like to help you with that. I mean, one of the possibilities
of course is to bring them to some of the remaining training workshops and get the
master trainers trained that way. Lots of things we’re willing to support you with
but if you don’t ask us we won’t necessarily be able to help. So we’re, again, offering
our assistance. I guess Cori I’m going to let you take this part on.
Slide: Feedback
CW: I’m just going to put up a brief one-question poll. It’s really easy to answer.
You just click on your answer and it’ll calculate it for us. We have a few questions
that we wanted to ask for feedback which really we don’t have the time to do through
the webinar software. We want to give you a little bit of time to think about it
and we really value your feedback and we’re working really hard to implement it.
We definitely used suggestions from the last webinar for this one. So we have three
questions here and we’re hope you’ll take the time to shoot me a quick e-mail with
your responses. We’d like to know your general thoughts, things that you’d like
us to improve on with the webinars, maybe things we could do differently to make
the experience better. And then topics you’d like to see. These webinars are designed
for your benefit, so we’d like to really cover the topics that you want covered.
So I’m going to put up this poll and leave it up for a little bit. It’ll tell me
how many people’ve answered so we’ll just let you guys go through and answer. I’ll
leave it open for a minute or two and then we can move on again.
Slide: [ Poll 1 ]
DB: I am still on the phone and I am happy to answer questions.
CW: [Participant 4], it looks like you have a question if you want to go ahead with
that.
[P4]: Yes, thank you. This is maybe going to be a little rambling, but… I find,
I have not gone through any master training. I do have some of the, like the pocket
guide and the videos. I think it’s so massive. It’s a little daunting to know how
to get started. The ARHQ site has a lot of materials but it’s so dense. I did appreciate
the case study because that’s real life and it shows how, just some ideas on how
it could be implemented. That’s all. I guess it’s more of a comment than anything
else, but there’s a certain amount of feeling daunted and the massiveness of the
material.
DB: That’s why again I’d like reinforce that we’re here to try to help. So are you
with a QIO?
[P4]: Yeah I’m with a QIO.
DB: And your QIO has come to training?
[P4]: We have one person who went, well we had two and one person left the company,
so one person went to the on-site in-person training. But, you know, not everyone
can go. It’s my understanding it’s like a whole body of work. It’s like a resource
guide. I did appreciate the emphasis on evaluating where the facilities are at and
really spending time there and maybe selectively picking out tools and resources,
but I don’t know it’s a little bit overwhelming. You’re asking people a lot to commit
to the TeamSTEPPS program. So I don’t know. Thoughts.
DB: One of the things I think just to clarify that, and just a couple things because
now, if I understand correctly and don’t hold me to this if I am wrong because I’m
not part of the QIO but I’ve learned a lot from you folks and I appreciate it, is
now that the contract is in effect and you have that contract capability by august,
and I may have that wrong, and the next year will be spent rolling it out. Now certainly
it would not be inconceivable if you had passionate systems that you’re working
with and they were interested in coming with the master training that we would consider
helping in the sense that you could send that change team of the system that you’re
going to work with to one of our master training programs and then we would work
with them and when they came back to you we could even do a few hours of consulting
to bridge that gap and get that boat moving. I mean, we want this to work, we want
this to work for you in everyway possible. We realize it’s daunting but once you
just kind of try it and I think you guys have a lot of process improvement knowledge
and that’s what this is about, I think you’ll be successful. Very successful. So
it’s just a little bit about getting over the first hump and again we’re happy to
think of all sorts of strategies to help you get over that first hump or get some
of those people trained or do some additional webinars on, on, even if it’s just
going through the curriculum again or whatever would be useful for you. The only
thing we’re probably going to ask to come back is for you to share your success
stories with us because we want to know this is working for you. Other questions?
[Participant 5]: Dr. Baker, how can we bestow master trainer status on someone we
fully trained?
DB: Well, are you a master trainer already?
[P5]: Yes.
Slide: Feedback (01:18:53)
DB: We had a lot of conversation on if you could certify someone for this, and since
AIR, I mean ARHQ, we are kind of regulatory in that way. So I guess if you put somebody
through the two and a half day curriculum and I suppose if you wanted the knowledge
test that you all took when you came through the master training you can use that
same model as a master trainer. I guess once you become one you can make some. That
would be fine, you know. That is the dissemination plan. The idea and my understanding
is because the contractual requirement from the QIO is to send two people those
people can come back and create additional master trainers. I do know of organizations
by the way that have had successful implementation with no training whatsoever.
So they got the materials themselves, they blasted through it, and got all their
quality folks together and figured out what to do and moved forward and tried it
and adapted it along the way. I hope that answered your question. Other questions?
CW: I think we can move on.
DB: Any other questions Cori? Because we’re just about out of time.
CW: No, I only just had one about getting the interview questions, but we can just
e-mail that to them later.
DB: Yeah, we’ll have to figure out what to do about that. We may even do that as
a separate topical webinar because the interviews are not, I would have to think
about that. It’s a very successful tool, you should think about talking to the staff
to figure out what their needs are, you can learn a lot in talking to about 6-8
people. We used a tool to help us do something. If there’s enough interest there
that’ll certainly drive my decision on what to do with that. If the one person who
is interested wants to contact me I am happy, happy to talk to them on what we’re
doing in more detail, which was the purpose of this call to give them some insights
and get them some more information. Not sure if we’re going to put that out as a
public product or if it’s ready for that now or not. So again I’m always happy to
talk about this, any of the staff that are on this project are. Any other questions?
CW: Not on this end, no.
DB: Well, I want to thank everybody for the time and I know it says there are more
slides on here but they aren’t really anything of substance at this point, and we
appreciate you all listening in and keeping your phones on mute. So, thank you very
much.
Slide: Seeking More Information
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