National Implementation of TeamSTEPPS Webinar 3

Determining Organizational Readiness for TeamSTEPPS and Developing a Strategy to
Build Administrative Buy In

Moderator: Alexander Alonso
July 30, 2008

Operator: Ladies and gentlemen, thank you for standing by. Welcome to the Determining Organizational Readiness for TeamSTEPPS and Developing a Strategy to Build Administrative Buy In conference call. During the presentation, all participants will be in a listen-only mode. If at any time during the conference you need to reach an operator, please press star 0.

As a reminder, this conference is being recorded Wednesday, July 30, 2008. I would now like to turn the conference over to Mr. Alexander Alonso. Please go ahead sir.

Alexander Alonso: Good morning and good afternoon to all of you who are attending our third webinar for the TeamSTEPPS national implementation program. I want to welcome you all and hope that you all get as much as you can from this particular learning activity.

As you know, today’s webinar will be covering topics such as determining organizational readiness for TeamSTEPPS, and developing strategies to build administrative buy in. Today’s presentation will be facilitated primarily by Dr. Rebecca Beard. We call her Becky. She is from the Group for Organizational Effectiveness, which is a very prestigious training and research group out of Albany, New York.

They’ve worked with quite a few organizations - leaders in industry ranging from IBM to NASA. Having said that, I’m going to go ahead and give some introduction material and then we’ll go ahead and get started with this particular webinar activity. Should you have any questions, we do ask that you use the Q and A tab up top to send us your questions.

Please do send the questions to Corinne White. She is one of our co-presenters, one of our facilitators, and she will be monitoring the questions. At given times through the entire learning activity, Corinne will go ahead and stop us, and we will address questions post by you and other participants. Thank you very much.

So on today’s agenda, we are going to go ahead and discuss who we are, and by we, we mean The American Institute for Research, and what the national implementation of TeamSTEPPS program is. Then we will get in into the topic areas, including determining readiness and building leadership buy in.

Then we’ll address some questions and provide you with contact information for further questions and future webinars.

The national implementation program is run by the American Institute for Research, which is a prime contract - which is the prime contractor for this contract. It is a not-for-profit, non-partisan research organization based in the District of Columbia. We have 11 offices in the United States, as well as 12 international offices.

We’re focusing on research and policy research, including health policy, education and work force assessment and work force strategies. Our staff include health services researchers, nurses, physicians, other clinicians, as well as social and behavioral sciences. The overall mission for our organization is to better society through our research.

The national implementation project or program, as we refer to it, is the - it is three objective program sponsored by the Agency for Healthcare Research and Quality and the Department of Defense TRICARE Management Activity, with the aim of creating a national infrastructure to support the adoption of TeamSTEPPS. Among the pieces of this national infrastructure include staff from quality improvement organizations, many of whom might be on the line here today.

Members of the Patient Safety and Recruitment Corp. And other action partners and higher liability organization network partners of the Agency for Healthcare Research and Quality. The goal of this entire program is to make training available to early adopters of TeamSTEPPS. And by early adopters, we’re referring to M. Everett Rogers’s theory of diffusion, and the early adopters is where we are in this stage of diffusion.

The goal is to spread TeamSTEPPS nationally, and make sure that there is a solid infrastructure of master trainers to support TeamSTEPPS in the future. The goal again, is just to create 1200 new master trainers. This project is again, led by the American Institute for Research, which is seen here as AIR in the District of Columbia. We are supported by four primary team resource centers where the training is provided.

These include the University of Minnesota, Creighton University, Duke University, and Carilion Clinic, out of Roanoke, Virginia. Along with these primary team resource centers, we also have other partners including the QIOs Lumetra, and Delmarva Foundation. And we have two other support contractors who are helping us with the evaluation of the overall national implementation program.

These are; The Group for Organizational Effectiveness, which includes Dr. Rebecca Beard’s work, and Booz Allen Hamilton, who has been supporting us with a great deal of the National Implementation Project). As mentioned earlier, the sponsors for this are a - are the Agency for Healthcare Research and Quality under the Department of Health and Human Services, as well as the TRICARE Management Activity under the Department of Defense.

They have been the leaders in the development of TeamSTEPPS, as well as the implementation of TeamSTEPPS, both publicly in the public sector and in team consists of Dr. David Baker, who is the Project Director and oversees the entire program. He has a dual appointment with the Carilion Clinic also, and other members including myself.

I’m the Deputy Project Direct for Research and Research Activities, while Deborah Milne is the Deputy Project Direct for Outreach user support and recruitment. Cori White, or Corinne White, who is on this call, is also our leader of administration. As you can see here, we are an interchangeable team. You can contact any one of us and we can supply you with the appropriate user support that you might need.

For contact information, you can contact us at any one of these emails or any one of these numbers. In addition to these, we - if you would like to contact us regarding these webinars or these learning activities, you can contact us at teamsteppswebinars@air.org. That is all one word - teamsteppswebinars, all one word, @air.org. At this point, I would like to go ahead and turn it over to Becky.

And if there are no major questions or administrative information that you require, we can go ahead and get started.

Corinne White: And Alex, I have just two things really quickly. This is Cori White. For those of you who are looking for a hard-copy handout version of the slides, they’re available at the top-right of your screen. There’s a little button that looks like three pieces of paper, which should let you download the PDF version of the slides. And in addition, the email that Alex had mentioned is teamsteppswebinars, plural, @air.org.

And if you have a question about the webinar, that’s a really good place to reach us.

Alex Alonso: Thank you Cori.

Corinne White: So, go ahead Becky.

Rebecca Beard: Great, thanks guys, appreciate it. Well, as Alex mentioned, I’m from the Group’s Organizational Effectiveness, and we call ourselves gOE for short, because it’s a little easier to say. And we’ve been asked to create a tool that can assist institutions in deciding whether or not they’re actually ready to implement the TeamSTEPPS program. And so what we’ve done is we’ve created on organizational readiness assessment.

And you can consider this sort of a litmus test to determine whether or not now is the right time to implement TeamSTEPPS. And what we have here are 12 questions that can help you decide that. The organizational readiness assessment is currently available on the web site, and I’ll show you a couple of screen captures of it, so you can get an idea of what it looks like.

But essentially, it’s based on research that comes from the TeamSTEPPS program itself, as well as some research - a lot of research that’s been done in the change area to identify what makes change successful. And this is really important because the TeamSTEPPS program is more than simply a training program. It’s actually a shifting culture towards safety and team work.

And so this makes it quite a significant change effort. So when we look at the research on change, what we find out is there’s good news and there’s bad news. I’ll give you the bad news first. The bad news is that research has consistently shown that more organizational change efforts fail or flounder than succeed, which is not good news. The good news however, is that research is starting to identify what makes change efforts successful.

And by successful, I mean able to be implemented successfully, able to change people’s behaviors, and also to be successful over the long-haul, over time. So the good news is, is that today what we’ll talk about is a few of those characteristics that make change effort successful. The tool that we created basically is intended to serve two purposes.

The first purpose is to educate people on what needs to be in place to get the full value from the TeamSTEPPS program. And the second purpose is to help institutions decide whether now is the right time for them to implement TeamSTEPPS. And so this litmus test basically clusters the questions, the 12 questions, into four areas.

The first is related to defined need. So have the institution identify what the problem is that they’re experiencing. Also related to readiness, the second area is the organization in the best state to take advantage of this change effort at this time. The third area relates to resources. Is there sufficient support to - for this effort? And the final area is around sustainment.

If the institution invests a lot of time and energy at the beginning of the change, are they willing to continue that effort over time to make sure that it’s successful?

And here I’m talking about things like coaching and on-going meetings. So the idea of this tool is provide some information that can help institutions answer the questions. What you see here in front of you now is basically a screen shot of the tool itself.

And what you have is this shows you the URL where it’s listed. If you click on the AHRQ site you can find it under readiness assessment. And what you have here, the 12 questions, along with a little bit of additional information. So for example on this first question, I expanded to explain, and that gives you this information here.

You would then identify whether you could answer yes or no for your institution to this one question and continue down the assessments. So let’s start off by kind of giving a little bit of a greater background and information on the 12 questions. And we’ll also dig in a little bit deeper as to why these questions are important.

So in the area of defined need, there’s two main questions that we’ll look at. One it is has your institution clearly define a need that’s driving you to consider TeamSTEPPS, and is building a stronger team work and safety culture an appropriate strategy for you? In terms of the first question related to defined need, it’s really important for an institution to understand why it needs to change.

And the reason for this is because it helps you build a business case for making the change. And it also helps individuals to be able to buy into the change more successfully, because they understand the rationale of why it’s occurring. There’s been a great deal of research on change, and some of the research has shone that organizations that are successful over time can lead to sort of what we call dysfunctional persistence.

And also individual resistance to change. And what I mean by that is if an organization’s been successful, they continue to do what made them successful at that time, regardless of whether or not it’s what they need to be doing at this point in time. So that’s how you can get a little bit of dysfunctional persistence and individual resistance.

So it’s really important to have a clear rationale for why you’re going to implement this change effort. Especially since change efforts typically take anywhere from 12 to 30 or more months to actually implement and succeed. And so it’s a great deal of time and effort that people put into this. And we’ve seen some research from the Conference Board that actually tells us that a lack of urgency and an unclear rationale are the two of the most common derailers of any change effort.

So that just again, emphasizes the importance of it. So TeamSTEPPS is designed to improve quality and safety (unintelligible) team work within the institution. And so that’s the need that it addresses. So it’s important to gather information about - to support the need within your institution. And this also helps to eliminate a little bit of that, you know, I heard about this great program, maybe we should do this.

It helps you provide the rationale and the reason and gather the data for actually making the change. The second question related to defined need is about building a stronger team work and safety culture. And it’s really important that there be a match between the need that your institution is experiencing and the approach that you take to meet that need or to solve that problem.

So team work, plus TeamSTEPPS focuses on enhancing safety through team work. And we know that team work skills are very important in reducing and minimizing medical errors. There’s been a lot of research on that. So if an organization has a need that they don’t think can be met by emphasizing team work, then it may not be the best time to begin TeamSTEPPS.

And part of the reason we say that is because no one is going to say that they’re against safety or, I’m against team work. But the question is, is it the best solution for your institution at this time? And so one of the things that you can do when you’re thinking about implementing TeamSTEPPS is assemble a business case that helps define why; the rationale and the need that TeamSTEPPS is going to meet.

The second sort of cluster of questions is related today a readiness for change in the culture. And this focuses basically on three areas. One is timing, the second is feasibility, and the third is leadership support. And we’ll get into this in a little bit more detail.

Looking at timing, timing is critical in any change effort because, if, for example, your organization is experiencing multiple major changes at this current time, it will be difficult to gain enough momentum to implement the change effort.

The conference board has done a little bit of research on this and found that having too many changes underway is one of the most common reasons why change efforts fail. And so what happens is people’s attention gets divided and they’re not able to focus on the specific change in - that’s being done.

And all of us have probably experienced it sometime, being an institution or an organization where there’s a lot of changes either going on at the same time, or there’s one change right after another. And what happens is it makes it really tough for any one change to stick and for the behaviors to be changed within the organization.

And we’ve actually heard this called sort of the flavor of the week change in some of the institutions that we’ve worked with. And so, this makes it difficult to get buy in from individuals. I’ve actually heard people say, you know, if I just wait long enough, this is all going to go away. So the idea here is to make sure that there’s not other changes that are going to go - going on at this time that will prevent TeamSTEPPS from having the big impact.

And so what you can do is you can postpone implementing TeamSTEPPS. Even delaying for a few months may make a big difference in the success of the program. The next question is related to, is a culture change that emphasizes team work and safety feasible? And so the main question is, will emphasizing team work be acceptable within your organization?

Is the work environment sort of team-based, or is it mainly focused on individual effort? And so that will tell you whether or not it might be open to this sort of change. And so TeamSTEPPS involves changes for both people and processes. And so it requires recognizing that there’s a need, developing a culture to support that, fostering the change in individuals’ behavior, and then finally changing processes, if necessary, to make the change a success.

And when we talk about enhancing team work, which is the main focus of TeamSTEPPS, what we discovered that means providing individuals with a little bit of freedom and discretion that they may not currently have. It involves opening up to a little bit more risk-taking behavior, which we know in the medical community is a little touchy.

And also, people finding their own solutions to things. And it may not match the current processes or procedures with your - within the organization. And the organization needs to be able to accept that and work with it. The next question is related to leadership support. And there’s been a study that was done within 225 organizations that found that leader commitment is related to organizational success.

And so when we talk about involving leaders in the TeamSTEPPS program, this goes beyond sort of simply saying, yes, I think this is a good thing to do on the behalf of the leaders. But knowing - having them know what’s required of them and being able to make judgments about whether they’ll be able to participate in the program. And that means things like providing resources, sponsoring a program.

Determining whether the program is succeeding through evaluation efforts, and displaying the required behaviors themselves. So we want the leadership then to be involved in displaying team work behaviors that can be modeled for the rest of the organization. And so one of the key learnings that we can take from this is sort of involving key influences early in the process in implementing the TeamSTEPPS program.

So I don’t know - Cori, is this a good time to stop for questions?

Corinne White: It looks like the questions that we’ve had so far have been covered. The only one question was about - the question was, has anyone applied the framework of John Kotter’s leading change to TeamSTEPPS? And the answer is yes, it’s based upon Kotter’s work. Actually, Dr. Kotter served on the initial TeamSTEPPS technical expert panel. So that’s where some of this came from - in fact, most of it.

Rebecca Beard: Good. Hi, thank you. So the next sort of cluster of questions that we have relate to investing the time, resources and personnel for the program to be a success. And so part of this is having a sufficient number of people to be trainers and coaches, and having those individuals have the right characteristics to be trainers and coaches.

Providing the time for them to be prepared for that role; allowing time for people to attend the training - physicians, nurses, staff; and also time to customize the course. And we’ll talk about each of these in a little bit more detail. When we look at providing sufficient staff with the necessary characteristics, this is looking at sort of two things.

One, do we have the right number of people, as well as do they have the right characteristics? And there’s been a great deal of research that shows the importance of having confident, knowledgeable, credible instructors who have good training skills; and so part of this is making sure that you have sufficient people within the organization who can provide the training, and that they have those characteristics.

And so when we talk about having sufficient staff with the right characteristics for the TeamSTEPPS program, we’re talking about having advocates of team work and people who will model team work on a daily basis. People who have the about to work in interdisciplinary teams, who are dynamic presenters - we’ve all been in presentations where someone was a little bit less than dynamic and, so that’s always good.

Who are viewed as credible, and leaders within the organization - and this means that they’re actually able to influence others. And finally, they have the flexibility and availability for coaching. They have the time that they can spend on that to sort of sustain the effort over time. And so the question for the institution is, do you have the individuals with these characteristics who can service trainers?

The next question is related to sufficient staff to serve as coaches. And TeamSTEPPS actually goes beyond training. You’ll remember initially I said it’s a culture change. And so the culture is actually changed through monitoring and reinforcing team work over time. And so there’s an initial training piece of this, but there’s also coaching on whether or not teams are actually displaying the right team work behaviors.

And it’s about having the right number of coaches. So for example, the ratio that’s recommended is 1:10. And so if we look at the research related to this, what we find is that in general, people learn more on the job than they do in classrooms. And so coaches and supervisors are key to insuring on-going learning and reinforcement of training.

And so it’s really important to have the coaches available to kind of reinforce the team work behaviors on a daily basis. We find that research has shown that even one negative comment from a supervisor after someone has been through training can actually eliminate all of the good effects that they had from going to that training.

So it’s very powerful influence that supervisors and managers have on their staff. And so when we look at coaches, the characteristics that we’re looking for are things like being competent to develop other skills, being able to influence change on many different layers, and we’re talking about work patterns, behaviors.

And even within the environment, if there’s something that’s sort of reducing the ability to have team work. Having a style that supports coaching, and finally being able to provide effective feedback; and so these are the characteristics we’re looking for in the coaches who might participate in that TeamSTEPPS program.

The next question is related to allowing individuals time to prepare for their role, and trainers and coaches. And so again, this goes back to the research. If you have trainers and coaches that are competent, credible and knowledgeable, it just makes them much more effective in doing what they need to do. And so it’s important for an institution to make a decision regarding their ability and willingness to properly prepare their change agents.

And by this, we mean their trainers and coaches. The next question relates to allowing sufficient time for personnel to attend training. And the training in the TeamSTEPPS program can vary in length, for example, it can be from one hour up to six hours; but requires individuals to be dedicated to attending the training and not dual tasking.

This is something that we’ve heard from several different individuals who’ve already implemented TeamSTEPPS program, is it’s very important to dedicate specific time for individuals to attend the training, and for that to be kind of not interrupted with any other items. And if we look to the research related to this type of training, we find that training motivation is related to learning and performance.

So this means that if trainees have time to attend the training, and it appears to be relevant to them, then they’ll get much more out of it. They’ll be more motivated over time. And so we need to provide the time for them to attend it, but we also need to customize the training, which brings us to the next question. As I mentioned, to have the most impact, training should be customized to some extent to participants.

For example, emergency versus labor and delivery; and the nice thing about TeamSTEPPS is it provides the about to customize the content for that specific domain. But again, this requires a certain amount of time and effort on the part of the trainers and coaches. And so the question is, is the institution willing to provide that time and the resources?

The final set of questions relate to sustaining the change over time, and this involves measuring and assessing the success of the program, and continuously improving processes. The other piece of it is reinforcing and rewarding positive team work behaviors. So once the TeamSTEPPS program has been implemented, the question is will the institution be willing to measure and assess project - process.

So as the change unfolds, it’s important to find out why it’s working or why it’s not working. And to be willing to make the changes that are required to continually improve the process or the procedures that are used, or the team work behaviors for individuals. And the reason that we’ve asked this question is that research shows us that what happens outside the classroom greatly influences whether or not skills are applied. And so we need to constantly assess what’s working, reward the right behaviors when people do what’s expected of them, and make the necessary adjustments over time. If we find something’s not working, we need to make the changes to increase the likelihood of success. And the TeamSTEPPS initiative involves constantly measuring effectiveness, identifying opportunities for safety and quality improvements, and then implementing these changes.

And this can be done by leaders, trainers or coaches providing on-going feedback to others about how well or not well they’re exhibiting these behaviors. And also formalize - formally recognizing successes. And what these do is this conveys that the organization is committed to the change effort, and that they’re willing to spend the time necessary to see that it’s successful over time.

And so the question is, is the institution ready to take the steps to sustain the change over time?

Rebecca Beard: So, what we have here is, we’re looking at the web site again, and so if an organization - if someone from an organization went into the web site and answered these questions either yes or no, based on the current status of their organization and whether they felt the resources would be committed, they would then get a summary of the results.

And so that’s what you see here in the red box. And basically, it tells you the number of yes responses that ever been recorded, and then gives you a little bit of information about those results. And in addition, it also points you to some tips and suggestions that can be used to enhance readiness before implementing TeamSTEPPS.

And so what we have here is I’ve just also taken a real quick screen capture of the tips and suggestions page on the web site. And so what you see here, just a few other tips and suggestions.

Corinne White: Hey Becky, is this a good chance to stop for questions?

Rebecca Beard: Sure.

Corinne White: We have - the first one that I’m going to start with is, who should complete the assessment in the organization?

Rebecca Beard: It should be someone who has sufficient knowledge about these items. So it’s got to be someone who either is familiar with your executives or has a good feel for whether or not they’d be willing to provide the time and resources to implement TeamSTEPPS.

So if someone who has less information completes the questions, it might not be as successful.

Alex Alonso: And I would like to add to that. It is often, a team of individuals who will complete this assessment. It might be the precursor to what we call the “change team” or the groups who are - the group who is seeing the need for change. So oftentimes it’s a group of individuals, and not just one person. But they do need to have that access to information. Cori, the next question.

Corinne White: Yep, the next question, we’ve been asked to expand on dealing with resistance, especially physician resistance.

Rebecca Beard: I think one of the main reasons for developing the rationale for the program is to provide some evidence that it’s important for the institution to make this change. And so I’ve heard of examples where a physician was very resistant to the program.

But participated in the training and ended up being one of the trainers themselves over time, because they actually - once they got into training, they understood what the program was about. They bought into it, and they understood how it would improve or enhance safety and team work within the organization. I think most physicians are very much influenced by evidence-based research.

And so being able to present them with some of the findings related to the importance of team work and enhancing patient safety, and the research that’s been used in developing a TeamSTEPPS program would hopefully convince them that it’s a good change to make.

Alex Alonso: I will give another anecdote that I have heard in the past, especially dealing with physician resistance. And I think John Webster, I know is online, and he actually posed this question. But I think it’s a very good question and one of the reasons that I - one of the anecdotes that I have heard - not from John, but from others - is that you really oftentimes have to bargain with resisters or individuals to help them kind of achieve a goal that they are interested in.

And then trade that off with them helping you with this goal. And that typically is the first step to buying in with resisters. And then getting some more buy in the future. And especially if there’s success, once you have success with one particular initiative, it really, you know, leads to future successes and less resistance.

Rebecca Beard: And one of the things - one of the tips and suggestions that we recommend is actually finding a - sort of a champion; a physician champion, a nurse champion, a champion from several different areas within the organization, to try to serve as an example and to convince others of the importance of the program; and so if you need individuals at all different levels within the organization to create the buy in and to be able to convince other people of the importance of it.

Corinne White: Okay, the next question we have says, “In our organization, we need more training more often. In the military and contract employee setting, we have a high turnover of staff personnel. What local facilitators are required? Please provide advice.”

Rebecca Beard: When I look at this question, I guess one of the questions I would have is, is it - is the need for more training because of the high turnover of personnel, and what’s preventing that additional training from happening.

So it looks like you need facilitators. And that would require training more individuals to be able to facilitate the program. But the other question then is, if you’ve got a high turnover of staff personnel you’ve probably got a lot of learning that’s going on within the organization in terms of just job-specific information. So, I guess my question would be is it a resource issue, or is it a time issue that they’re trying to deal with?

Corinne White: We have a question now, it says, is there a script available to talk to senior leadership about TeamSTEPPS and get their buy in?

Rebecca Beard: Actually, that’s a great question, and it leads to what we’re going to be talking about in the next few minutes. So we’ll be talking about sort of an executive briefing that can be given to provide this information.

So if you could hold on for just a few more minutes, hopefully we’ll answer that question.

Alex Alonso: Sure. I do want to tackle one of the questions, Cori. And I’m reading the question and it says, can TeamSTEPPS be implemented in a functional area, say the ER, as opposed to the whole organization? Is there such a thing as a pilot program, for example? And the answer to these - to this question in particular is yes.

And it - and by yes I mean a good number of the organizations where we have seen great success has been with implementation in one unit. And so it’s starting with one unit, and then with success in one unit, that having that spread to other units. That is not the only model. We have seen other models where we’ve had hospital-wide or organization-wide implementation.

But with that comes extreme logistics and more resistance given the number of staff that would be involved; but, but to answer your question, a good number of the places where we’ve seen great success have included implementation starting with the ER. Other examples that we’ve seen, and I know for instance, at the Carilion Clinic, we - they have started with implementation of TeamSTEPPS with their rapid response teams and with the pharmacy.

And so the successes there have spread to other units and more demand from other units to really build buy in. So the short - the long answer to your question or the short answer to your question is yes.

Corinne White: And that seems to be all we have for now, if you’d like to move on, Becky.

Rebecca Beard: Okay. So as I mentioned, the next part of the webinar is basically talking about an executive briefing overview that we’re working on now. It’s in its final stages. And the purpose of this is to present the TeamSTEPPS program to senior executives, for example, a CEO, the CNO, Senior Leader of Quality or Patient Safety.

And this briefing is essentially designed to provide a very high level overview of the TeamSTEPPS program to create a general understanding of the process. It presents a little bit of research to support the importance of team work in patient safety, defines what’s needed for the program to be successful within an organization.

And the goal of all of this is to help build buy in from senior executives and to gather their support for the program. This is one of the things that we’ve heard a few times. It is really, really critical in making sure that TeamSTEPPS is successful is in establishing senior executive buy in and getting their commitment, not just for the training program, but also for the long haul for the changes that are necessary and need to be sustained over time.

And so basically, what we’re creating is a PowerPoint presentation that has slides and presenter notes, and within the notes it suggests specific areas for customization to make the presentation a little bit more relevant to your own institution. So for example, some costing information or something like that.

The idea being that it is a presentation that’s sort of contained, but it also can be customizable as well. And some of the topics that are included in the presentation, it basically just provides a quick snap shot of sort of the rationale for the program; the evidence-based research that supports its use.

How TeamSTEPPS differs from some of the other team work programs that are out there, what teams will learn by going through TeamSTEPPS - sort of a basic background. The process for implementing and maintaining the program, what’s required to make it a success over time, and then getting started in some information on potential costs.

And then the training that’s available currently to support the program - training for trainers. So this is sort of the major topics that are covered in the executive briefing. And the goal is provide a sufficient level of information to inform senior executives about what’s required to sort of minimize surprises about the program. And also to get their support for implementing the program.

And as I mentioned earlier, senior leader support is really critical in making sure that the program is a success. Are there any questions about the executive briefing?

Corinne White: We have one that says, should the Board be educated at the outset, or begin first just with the C suite?

Rebecca Beard: I would probably recommend starting with the C suites, to make sure that there’s buy in at that level. And then based on the relationship you have with your Board, then informing the Board as well.

I guess part of it depends upon how hands-on your Board is in oversight of the institution. The more hands-on they are, probably the sooner they should know. If they’re more of an oversight, hands-off Board, they might just want to be informed about what’s going on.

Corinne White: Okay. We have two questions that both ask if the executive briefing is available yet, or when it will be and where?

Rebecca Beard: It’s not available yet. I think our goal at this point is to get it up and running sometime in August. I think it’s under review right now by a few other individuals who need to take a look at it and give us some feedback.

Alex Alonso: And just to confirm what Becky said, the goal is to go ahead and have it - to have it by the end of August, or the beginning of September. And once it is available, it will be made available - if I am not mistaken - it will be made available on the TeamSTEPPS web site, at ahrp.gov.

Rebecca Beard: And I see that somebody has their hand raised in the seating chart. If you have a question, please just go ahead and enter it through the Q and A tab at the top. And we’ll make sure that it gets answered. And I think - let’s see, are there - there’s one more question that I think we have. It says, is there a business case developed for implementing TeamSTEPPS? Alex?

Alex Alonso: I’m going to go ahead and tackle that one. There is a business case. It’s a case developed for implementing TeamSTEPPS. A good number of them - well, there’s a couple of pieces of information that I think are useful here. In 2006, there was a - an article in the Contemporary OB/GYN, which came out which highlighted the relationship between team training and clinical outcomes, as well as the costs associated with clinical outcomes.

And in particular, this group highlighted - and this group was part of the TeamSTEPPS development group, and they were using a TeamSTEPPS-based team training initiative across their labor and delivery unit - and what they found was that they could reduce, by implementing team training, they could reduce the associated costs with adverse events by about 50%, whether it be through malpractice insurance reduction or just the overall cost of the event itself.

Having said all this though, if you want more information about the business case for implementing TeamSTEPPS, we would recommend that you do one of two things:

Either email us, so that we can provide you with the references that deal with this business case, and the other thing that I want to point out is that there is a - as part of the leadership briefing, one of the things that we’ve been working with is a - we’ve been working with a leader in the leadership briefing area by the name of Mary Salisbury.

And she’s one of the preeminent trainers of TeamSTEPPS for the Department of Defense and for other organizations worldwide. She is like John Webster, who’s the other individual I referenced. They are kind of like the Deans of TeamSTEPPS master trainers, and implementing implementation.

And one of the things that they have developed is, or that Mary has developed as part of her efforts, is a cost formula for the cost of what it would take to implement TeamSTEPPS, and where the cost savings are in terms of hidden costs if you do not implement TeamSTEPPS.

So what the cost to you would be as an organization for not implementing TeamSTEPPS. So there’s a couple of reference materials that we can give you, but we ask that you go ahead and contact us, so that we can provide you, or furnish you with those reference materials.

Corinne White: We’re - I have here, I’m going to open up polls, since we’ve got a few questions about the webinar. And while you are clicking in and answering, we’ll continue to answer questions. There. We have a question that says, can you provide an example why a team work and safety culture would not be determined to be advantageous to an organization?

Rebecca Beard: The - a team work and safety culture would be advantageous to probably most organizations. I think we’ve seen a lot of research that shows that influencing and enhancing team work behaviors greatly increases patient safety and reduces medical errors.

The problem would be that if you have an organization that has not been focused on team work, that has a strong individual-based culture, then it will be a very difficult transition to make. It will require more time and effort, more coaching and more attention to try to make this change; and then maybe more resistance on the part of physicians or nurses or staff with any institution.

As well as potentially senior executives who are interested in more of an individual reward system, and individual attention, rather than a team work-focused approach. And so that’s the reason we talk about whether or not an institution is ready to embrace a team working culture, and being able to try to gain some momentum within the institution for a shifting of culture in that direction.

I don’t - I’m pretty sure there’s that sort of change would be advantageous from any institution. But there may be some things that you need to do to try to change the emphasis a little bit before you begin the TeamSTEPPS program, or be willing to expend the extra time and effort that might be required.

Corinne White: Thank you Becky. I’m going to put up one more poll. If you give me just a moment to close the poll. This is your second question, please discuss and answer in the same way as you did before by clicking on your choice. It looks like there are few people who have purple dots on their seating chart, which means that they have their hands raised.

If you have a question, again, we ask that you enter it through the Q and A tab at the top of your screen, and we’ll make sure it gets answered. And again, if you want the slides from today’s presentation, they can be downloaded through the handouts button at the top-right of your screen, which looks like three little pieces of paper.

Alex Alonso: I would also like to add that I see some questions about the leadership brief or the executive brief coming this coming month or the month after that. And I will point out again that it will be available via the web site, and we’ll do all possible to go ahead and make it available to everyone, especially our master trainers who have been involved in the master training workshops already.

Okay, we’re going to go ahead and give you two more seconds here before we close the poles. And then we’re going to turn it over for a few more questions in case anybody else has anymore questions. And that will be all. Okay, Cori, have we closed the second poll?

Corinne White: Yep, the second poll is closed. And I have a question here that I’ll answer for everyone. It says, I missed the other webinars. How can I access the past webinar information? If you just send an email to teamsteppswebinars@air.org, and mention which webinars you’re interested in, we can make sure that you get the materials from that webinar.

Alex Alonso: And at the moment we have transcripts. And if the - it is uncertain yet as to whether or not we will make the recording available just yet.

Corinne White: The next question says, returning back to staff turnover, do you recommend follow-up post training to determine if training has been effective, or to see if the champion has left the organization?

Rebecca Beard: I think this is part of the sort of on-going monitoring and assessment evaluation process within TeamSTEPPS.

And I think it’s important to do some analyses to determine whether or not the program has been effective in changing behaviors of team members. And that would sort of identify whether the training was effective or whether or not there’s sufficient coaching that’s on-going to try to determine - to reinforce the training that occurred on the job.

As I mentioned earlier, the impact of the - being on the job has on training and training transfer is pretty significant. And so you might want to do some sort of evaluation as to whether or not the training itself was successful, and modified behaviors. And then whether or not that is sustained over time, which might tell you a little bit about the coaching experience and whether or not that’s been successful as well.

And if you find out that things are changing within the organization, if you have a champion that leaves, it will probably most definitely affect the success of the program. And in that case, it would be very important to identify another champion who could take their place to try to model behaviors, continue to get buy in from other individuals within the organization, and basically to sort of oversee the on-going effectiveness of the program.

Corinne White: Okay, the next question, is there a number of too many champions?

Rebecca Beard: I’m not sure there can be too many champions, unless you end up with competition between champions. But the idea could be that individuals who will support and foster the program will help send it out throughout the organization.

The more individuals who you have sort of championing the program, the greater the likelihood is that it will catch on and be effective throughout the organization.

Alex Alonso: I do think that one thing that I would like to add to that question is, is this is just from my experience in supporting TeamSTEPPS implementation, is that you - it is not possible to have too many champions. However, the key is to keep your champions tasked, so that they are not feeling as though they’re underused or underutilized for the particular initiative.

And I think that that is something that people do lose sight of. Is that sometimes the initiative is not moving as quickly as you’d like, and there are not enough tasks for your champions. And that’s where you have champion turnover a good deal of the time.

So, I do want to address one other question here, and the question is, have you had any experience with the instructor coming from an outside organization, and then the coaches from the inside - from inside the organization?

And how well has that worked?

I’m going to go ahead and say that in the past we have seen experiences where instructors have come from outside an organization. And in fact, initially TeamSTEPPS was - it was training from - by instructors from outside the organization. And it’s been - the Department of Defense, I know that the instructors actually come from the Department of Defense TRICARE Management Activity and support the facility, seeking the overall initiative to be trained.

Other examples that I can think of include having a - an instructor who was clearly expert in the area of change management come in and serve as part of the instructor group for an organization, even though they were from a rival university that - or universe academic health center that - in the same city. And that seemed to work fairly well, as long as the stage was set properly.

And by setting the stage properly, I mean, you know, making sure that you have an individual who is considered expert, someone that there is a case for including this individual as part of the instructor team, and that there is - that it is clear and transparent to your audience why this individual will be part of the team.

Cori, do we have other questions?

Corinne White: Yep, and the next question is, what types of measurement strategies do you suggest to determine success?

Alex Alonso: Becky, do you want to tackle that one, or would you like for me to tackle that?

Rebecca Beard: Why don’t you tackle that?

Alex Alonso: Okay, at present, we’re working on a bunch of measurement strategies, as well as a bunch of different means for evaluating the impact of TeamSTEPPS. Having said that, the - one of the things we’re - one of the areas where we’ve seen strategies for measurement for determining success include doing pre and post evaluations of your implementation.

And so that might include using the AHRQ hospital safety, or hospital survey of patient safety culture, which is publicly available both before and after your implementation of training, obviously, knowing full well that you’re going to need to leave enough time for the change to have taken effect.

Other things that we might suggest include finding team markers that you think are of interest, behavioral markers that you think are of interest that people can track over time to see if there has been a change. Best example that I can think of comes from one particular group that we work that is particularly interested in setting up two key initiatives.

One is providing standardized protocol for communication, so the use of SBAR, as well as doing, or limiting the number of interruptions over the course of the shift. And so what the group is doing is gauging their success by the number of interruptions and the overall self-reported interruptions that might be reduced.

The reason that they are targeting interruptions in general is because they did a self-study of their organization, and found that one of the precursors to medication error, or the potential medication error was that the clinicians were interrupted along the way to setting up medication orders. And so, that is one area where they are specifically targeting a precursor to assess the success of their implementation.

The key is really to study your own organization and identify what areas you want to target, and what behaviors you want to target. And think of it from that angle first. What are my target behaviors, and how can I gauge or set up measurements or measures for those target behaviors?

Again, of course, knowing full well that there are several measurement strategies or tools for evaluating the initiative that are on - through the - going through the validation process as we speak, the development and validation process as we speak. Cori, do you want to toss up another question?

Corinne White: Yep, the next question is, will there be more printed materials - calendars, posters, etc., for 2009? We found that posters and calendars served as good reminders.

Alex Alonso: This is a question that I do not have a complete answer for. And so I do not want to give you an incorrect answer. Having said that, I do know that the government printing office and the AHRQ clearing-house tend to make these available, but the demand is very high. And so they may run out pretty quickly.

Nonetheless, what we’ve kind of encouraged facilities to do is that oftentimes it might be less expensive for them to develop their own kind of customized TeamSTEPPS materials and trinkets. And so what we’ve kind of suggested to several organizations is to develop their own materials with their in-house printing group, or with a group that - a local group that can provide them with a more cost effective way of developing these materials.

Best example that I can think of is one that I would have to give David Baker and Charlotte Hubbard credit for at Carilion Clinic, which is they developed their own kind of penguin pens, which are about 80% penguin and 2% - or 20% pen. And the other example that I can think of from their group, is for the pharmacy they developed note pads for use by the pharmacy that had the TeamSTEPPS triangle on it and TeamSTEPPS lessons learned.

Another thing that comes to mind is Stress-guins, which are very similar to those stress balls that you might squeeze and to help relieve your stress, and they developed penguins that are for that very reason, they’re for that very purpose that are kind of, you know, dealing with the, or related to TeamSTEPPS.

So to answer your question, there should be more. I can’t speak for the federal government and say that they will be available soon. But we also encourage individuals, and we agree with you that they are great reminders and great tools, but we encourage organizations to go ahead and - as part of their customization of TeamSTEPPS, to go ahead and develop their own as well.

Cori, next questions?

Corinne White: Next question is, what are the most common mistakes that hospitals make when implementing TeamSTEPPS?

Rebecca Beard: In some of the interviews that we’ve conducted with various institutions that have implemented TeamSTEPPS, we find that it seems like the executive leadership not being - not having a full understanding of what the program requires. And so what ends up happening is TeamSTEPPS is considered to be a training program rather than an on-going cultural change.

And what happens is the resources are provided for the training piece of it, but not for the on-going coaching sessions and meetings and the on-going piece of it that actually helps create the culture change, and so that seems to be sort of one area, a mistake that can sometimes be made. Another is that there’s the potential for what we call getting - not having enough time and resources.

So everybody is really super busy these days. And so getting people into training and trying to help people figure out how to staff units and accomplish their work and also get people into the training program; it’s really important to have champions at all levels. To have a physician champion, a nurse champion, individuals that people can relate to and look up to.

And that the have been instances where perhaps a champion wasn’t well prepared for their role, or a champion left, there was turnover in champion that actually made it more difficult for the program to be a success. So these are some of the things that happened; in addition, sort of not establishing the metrics to actually evaluate the program when it first began to try to get some sort of baseline to determine whether or not the institution is improving.

So we’ve had several individuals recommend, you know, when you start the TeamSTEPPS program, combine it with another program that you already have that’s working. So for example, a quality improvement program, or something like that. And tagging the two programs together helps increase the likelihood of their success.

Those are some of the sort of the comments. You’ll also see, if you go to the tips and suggestions, you’ll see a few ideas there that are related to try to minimize those mistakes from occurring.

Corinne White: Okay.

Alex Alonso: I do want, Cori, I do want to address one question that I saw posted, and you may have answered it privately, but I knew - it dealt with the reference to the Contemporary OB/GYN piece. And one of the questions that was asked, was whether or not that was TeamSTEPPS based or MedTeams based. And the short answer to that is that TeamSTEPPS - that MedTeams had already been kind of phased out at that point.

Although there are great similarities between TeamSTEPPS and MedTeams is because MedTeams was a fine, and is a fine program. Having said that, one of the other things that we do want to point out is, and then one of the questions that was raised is, where is - where are there other sources of evaluation of success or evaluation criteria of successes for TeamSTEPPS?

And the answer to that is, is that there is a preponderance of the evidence that is coming soon because we have several evaluation studies going on, a lot of it dealing with socio technical probabilistic risk assessment. But there are several sources that are coming out. The other thing that is, it should be noted is that, AHRQ did go ahead and fund three groups this past fiscal year to conduct independent evaluations of TeamSTEPPS in their own office facilities.

And that those results will be posted - will be coming to the public, or be brought to the public light shortly. And so that is something to keep in mind, is that evaluation work is going on as we speak. But to the preponderance of the evidence that we’ve seen so far headed in the right direction; they’re showing an impact, if you will.

Another question that we have seen here is, don’t we get to see the results of your polls? Cori, I don’t know if we can make those results public. In other words, I don’t know how to do it with the system from where I am. But if you want to read those result, that would be fine.

Corinne White: Okay. I know how to make them public. I can do that, if people would like to see it.

Alex Alonso: Okay. Sure.

Corinne White: So, here’s the first one. And the second one.

Corinne White: And so we have another question. If says, which TeamSTEPPS communication behaviors or tools are least likely to have been taught or used in early doctor hospitals? For example, STEP.

Alex Alonso: Your STEP assessment? I don’t know that there is a least likely one that I can point to, necessarily. I will say that - and this is something I can’t take credit for - but that David Baker, our project director, can kind of take credit for, and this is from his experiences. Is that there is a TeamSTEPPS 101, a TeamSTEPPS 201, and a TeamSTEPPS 301 hierarchy of tools, if you will.

With the two challenge rule kind of being the highest order one. That’s the one for the most evolved hospital with the highest degree of - if, you know, a TeamSTEPPS engagement so far. Having said that, the key ones that kind of come in at the beginning are really the SBAR; that’s TeamSTEPPS 101, is implementing the SBAR, implementing briefings or briefs.

Implementing huddles; TeamSTEPPS 201 is kind of the debriefing and the other tools, like the, I need clarity or the cup tools. And the two challenge rule is really kind of where it really becomes a fully evolved TeamSTEPPS climate. I hope that answers the question.

Corinne White: Okay, our next question is, are there tools you provide for the analysis piece?

Alex Alonso: For the analysis piece? Am I - I don’t know which part of the analysis they’re referring to. I’m not sure that’s the analysis as far as the assessment of the site prior to TeamSTEPPS, or they’re talking about the evaluation piece. In either case there is a suite of Teams Steps measurement tools that are coming out soon.

As well as manuals for having to use these tools. One example of this is the team work attitude questionnaire, which is being developed for the DOD. And will be made public to the entire - to the - will be put in public domain. Other questions, Cori?

Corinne White: The last question that we have up here, if nobody else has one, is, will up-to-date info be sent regarding efficacy of the STEPPS program?

Alex Alonso: The answer to your question is that we will do our best to go ahead and provide this information as it becomes available and is ready for public consumption. We always do our best to provide that. And information like that can be found both on our web site, as well as on AHRQ’s web site.

Any other questions, Cori?

Corinne White: That’s the last one we had in the system. So if nobody else types one in, that’s it for today.

Alex Alonso: Okay. I want to give it two seconds here and then if that - if we’re finished. Okay, it seems like we’re answered all the questions that have come. So I want to go ahead and thank everyone who’s attended. I know we’ve lost a good number of groups with the number of questions that have come up following the PowerPoint.

However, I do want to thank everyone who was in attendance. I want to thank Becky Beard and gOE for their efforts on this webinar. And I want to welcome you all to the TeamSTEPPS National Implementation Program and should have any questions, you know how to contact us. Please do feel free to contact us, as we will be as available as possible to help you with anything.

And that should be it. Have a great day.

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