National Implementation of TeamSTEPPS Webinar 5

TEAMSTEPPS AND CRITICAL ACCESS HOSPITALS

Moderator: Alexander Alonso
October 29, 2008
12:00 pm ET

Operator: Ladies and gentlemen thank you for standing by and welcome to the Implementing TeamSTEPPS and Critical Access Hospitals.

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

As a reminder, this conference is being recorded Wednesday, October 29, 2008. I would now like to conference over to Alexander Alonso. Please go ahead sir.

Alexander Alonso: Thank you. Hello and welcome to the fifth Webinar in the series of TeamSTEPPS National Implementation Program Webinars. As you know, this one is somewhat of a continuation from the last Webinar, which dealt with using the AHRQ Hospital Survey of Patient Safety Culture in conjunction with TeamSTEPPS. This one relates to implementing TeamSTEPPS in Critical Access Hospitals.

With us today we have Katherine Jones, Dr. Katherine Jones who is an Assistant Professor in Physical Therapy Education at the University of Nebraska Medical Center. She was the primary investigator for an AHRQ funded partnerships in implementing patient safety grants entitled Implementing a Program of Patient Safety in Small Rural Hospitals. This project created a medication safety toolkit for small rural hospitals and identified the impact of systematic medicationary reporting on patient safety culture.

Katherine is an all around expert in the AHRQ Hospital Survey of Patient Safety Culture and she is also an expert, and one of the core TeamSTEPPS boot camp master trainers for the Creighton University Group that provides, or a team resource center that provides TeamSTEPPS training under the National Implementation Project.

She is also a member of Academy Health, the American Physical Therapy Association and a Board Member of the Nebraska Coalition of Patient Safety and the Nebraska Stroke Advisory Council.

At this time I’m going to go run through a couple introductory slides and then we’ll go ahead and begin the entire Webinar.

Just as a reminder we ask you to be considerate of others while participating in this Webinar. We ask that you please mute your phone to reduce any background noise, although we are in a listen only mode. Do not put your phone on hold if you have any hold music or advertising. And recognize that a conference call can never be better than the worst connection on the call.

Also I do want to make one editorial comment. We are in a listen only mode and we do encourage you to submit your questions and we will have a question and answer session at the end of the call, however, if you are participating on Live Meeting with the Live Meeting Software we welcome your questions via the Q&A tab at the top of the scroll bar at the very top.

Cori do you want to go ahead and run over some of what the basic features are of the live meeting?

Cori White: Sure. A little bit of the basic functionality, the most important thing that Alex mentioned is the Q&A tab at the top. This is at the top of your screen; if you click on it you’ll see a place where you can enter a question. If you have a question we prefer that you ask it through the Q&A tab and that way we’ll get it answered, and if we feel like it’s a question that many people have we’ll make sure that it’s addressed to the group.

The other two things that are very important that you should know about today are at the top right hand side of your screen. There is a drop down menu called Feedback with a bunch of colored squares and if you change the squares that gives us an idea of how you’re feeling about the Webinar. So if you can’t hear or you need us to slow down that’s where your feedback goes and we’ll try to keep that in mind.

There is an option that says you have a question, but if you have a question, again we ask that you do it through the Q&A tab rather than through Feedback because we are in the listen only mode.

The other important thing that you’ll see at the top right hand side of your screen is what looks like a little cluster of three white papers. If you click there that’s our handout tab and that’s where you can get PDF copies of the slides for today’s Webinar both in single slide format and three slide format with space for notes. There are also three handouts that Katherine will be talking about and those can also be found in PDF format at the, under the handouts button on the top right of your screen.

Alexander Alonso: Thank you Cori. Today’s agenda, we’re going to go ahead and briefly describe who we are, remind you all about what the National Implementation Program for TeamSTEPPS is, and then we’re going to go ahead and get into implementing TeamSTEPPS in a critical access hospital and specifically a system of critical access hospitals. Then we’re going to talk about lessons learned from implementing these hospitals in the critical access hospitals and then we’ll delve into some questions and provide some information for you all to contact us in the future.

So the National Implementation Program is funded by AHRQ and by the Department of Defense and the prime contractor for this is the American Institutes or Research. We are not-for-profit non-partisan research group based in the Washington, D.C. area. We have a total of 11 U.S. offices and 12 international offices that range in staff from health services researchers to nurses, physicians, social and behavioral sciences. Our mission is to better society through our research.

The National Implementation Program is, was designed by AHRQ and by the DoD to create a national infrastructure to support the adoption of TeamSTEPPS.

There was five main pieces, or six main pieces that would serve as this part of infrastructure, folks from quality improvement organizations who would serve as master trainers, folks from the Patient Safety Improvement Corps who would also serve as master trainers, as well as other folks from High Reliability Organizations Network, the AHRQ Action Research Network, academic medical centers and other health professional organizations that would help create or build a core of approximately 1,200 new master trainers for TeamSTEPPS nationally to help spread the TeamSTEPPS initiative nationwide.

For this we have four team resources centers, they are located at Creighton, Katherine is one of the key resources at the Creighton Team Resources Center. We have Minnesota, which is the University of Minnesota’s group, we have Carilion Clinic, which is located in Roanoke, and we have Duke, which is obviously located in North Carolina.

We also have a couple partners who serve as QIOs that have been responsible for our outreach efforts. These include Lumetra and Delmarva Foundation here on the East Coast. We also have several research organizations and training implementation organizations helping us with our efforts.

These include obviously AIR who is leading the whole project as well as Booz Allen Hamilton who has been instrumental in the DoD efforts, and the Group for Organizational Effectiveness out of Albany, New York that has been largely responsible for helping us providing technical support with the executive buy in leadership briefings and what not.

As mentioned earlier the sponsors for this are the Department of Health and Human Services and specifically the Agency for Healthcare Research and Quality and the Department of Defense and specifically the TRICARE Management Activity and the Healthcare Team Coordination Program.

The project team at AIR consists of Dr. David Baker, myself, Deborah Milne who is the Deputy Project Director for Outreach User Support and so much more; Rachel Greenberg who is part of our Administrative Group and Cori White who you all have heard from.

It should be noted that we are an interchangeable team and that any one of us are willing to answer questions as they come. Here are some contact information but you will see this again later on. These are just our e-mails and our phone numbers.

Okay Katherine, at this point I’m going to turn it over to you so you can begin the Webinar.

Katherine Jones: Thank you Alex. It’s my pleasure to be with you again and to share some lessons with you about what we’ve learned implementing TeamSTEPPS in Critical Access Hospitals. So in order to do that I want to first share with you some unique characteristics about Critical Access Hospitals so that you understand what the environment is in a Critical Access Hospital.

I want to describe for you the process that we’ve gone through to implement TeamSTEPPS in a collaborative group of rural hospitals that really spans two states, well three states actually.

I want to demonstrate some of the unique aspects that we’ve learned about when we’ve implemented TeamSTEPPS in our Critical Access Hospitals here in Nebraska. And then discuss what we’ve learned to be considered really universal lessons learned for implementing TeamSTEPPS for all of you out there that are struggling to achieve that improved performance in patient safety.

And then hopefully you’ll be able to adapt these lessons learned to your organization and take maybe a few pearls with you from this presentation to adapt to your setting.

So Critical Access Hospitals were created in 1997 as part of the Balanced Budget Act and at that time what we found out was that many small rural hospitals were closing because they simply could not meet the bottom line under prospective payment.

Prospective payment requires that you have a certain volume of, within a diagnosis in order to meet your budget requirements. And what we found was that small rural hospitals simply didn’t have the volume to remain financially viable under prospective payment.

So Critical Access Hospitals were created to maintain access to care in isolated rural areas and they receive cost-based reimbursement. So whatever it costs them to provide care for their Medicare patients they receive that amount of money plus 1% more. So for example typically about two-thirds of all of the patients in Critical Access Hospitals are Medicare patients. So about two-thirds of their revenue then is cost-based.

Critical Access Hospitals are limited to 25 beds, 25 in-patient beds and they are limited to a 96-hour average length of stay over a years’ time period. So on average your patients cannot have greater than a longer than 96 hours. So that requires you to either get people in, stabilize them and then move them on to another level of care.

They are characterized by limited resources financially, technologically, and in human resources as well. Technologically for example a number of the folks that I communicate with in Critical Access Hospitals still have a Hotmail or Yahoo e-mail address.

In terms of human resources it’s not uncommon for one person to wear multiple hats so you might be the Quality Improvement Coordinator, you might be the Risk Manager, you might be in charge of Infection Control, you might be the Director of Nurses, as well as any of those other tasks that I already laid out.

So there, in no way is there ever an entire department ten or 12 people devoted to quality improvement. At best there are one or two people and that’s their only job and typically quality improvement is just one of your jobs. So that’s one of the reasons that we wanted to provide some shared resources for programs such as medication error reporting as Alex mentioned in our first project and then in this current project for implementing team steps.

This next slide gives you a very graphic representation of the prevalence of critical access hospitals in the country. Critical access hospitals there are 1,289 of them currently and this accounts for about one-fourth of all the general community hospitals in the country. However, it only, we only account for 4% of all admissions so a high proportion of hospitals but a very low proportion of the number of admissions overall.

But you can see that critical access hospitals are concentrated in the Midwest in those areas that are characterized by low population density.

So this is a repeat of the slide that Alex showed you and what it demonstrates is where, oh I’m going to go, where we are in Nebraska we have implemented the TeamSTEPPS training program in 24 critical access hospitals, three network hospitals and each critical access hospital is hooked up with a network hospital that kind of serves as the mother ship for referral resources and hopefully for some infrastructure resources such as pharmacy support.

We do have one critical access hospital in Iowa that’s part of our collaborative and this summer I also kicked off a master trainer program in North Dakota where we trained 14 critical access hospitals.

So Alex stated that the goal was to supply 1,200 master trainers and with our work in North Dakota and Nebraska we’ve contributed about 158 master trainers to that goal.

This slide gives you an example of how all of our critical access hospitals in Nebraska are connected to a network hospital and the little purple crosses represent each of our critical access hospitals that are part of our TeamSTEPPS community. And here in Nebraska we have 87 general community hospitals and 26 of those 87 are now part of our TeamSTEPPS community.

And if you’ve read Malcolm Gladwell’s book “The Tipping Point” what we’re really trying to do here in Nebraska is create a tipping point where TeamSTEPPS, team skills and structured communication are simply the way we do business in healthcare and we’re trying to reach that tipping point by starting off with the core group that represents a little more than one-fourth of our general community hospitals in the state.

By way of background information, our TeamSTEPPS implementation project is rooted in our AHRQ funded project that was intended to implement the patient safety practice of voluntary medication error reporting and organizational learning. And we wanted to develop the infrastructure within these critical access hospitals to report and analyze medication errors, that infrastructure that you need to identify system sources of errors.

Well we were searching for a way to evaluate the impact of that reporting intervention on the culture of safety and that led us to the Hospital Survey on Patient Safety Culture. And the HSOPS really was our key to identifying our need for teamwork in these hospitals. And many of you that were on the previous Webinar understood the extent to which the HSOPS can reveal your need through teamwork.

And this next slide is an example of the domains and items within the HSOPS that are specific to team related skills. So this is an example of the HSOPS results from one of our hospitals and the first item, staff will freely speak up if they see something that may negatively affect patient care.

And these results refer just to nurses within one of our hospitals and you can see there that 83% of those nurses indicated that they were positive or that they were very likely to speak up if they saw something that may negatively affect patient care.

However you can also see if you look at item number 2, staff feel free to question the decisions or actions of those with more authority, you can see that there’s a big drop off between those that would speak up and those that felt free to question the decisions or actions of those with more authority.

And what the HSOPS does an excellent job of is identifying the gap between the belief that you function as a team and the skill. So we simply don’t have the skills to question the decisions or actions of those with more authority and very often speaking up and advocating for our patients requires us to question the decisions or actions of those with more authority.

Similarly the next dimension, teamwork within departments also demonstrates the gap between the belief that you function as a team and your skill. So the first item people support one another in this department, we see that 89% of the nurses in this hospital believe that they support one another but if we go to item number 4 when one area in this department gets really busy others help out we can see a big drop off between the nearly 90% that believe they support one another but only two-thirds say they help each other out when it gets busy.

And I can tell you that these patterns between the belief that you function as a team and the behaviors and skills needed to actually operationalize that belief there is universally a gap. I have looked at HSOPS results from over a hundred hospitals and if you just look at the national database report put together by Westat you continually see this pattern that there is a gap between the beliefs that we support each other and our behaviors to do so and that’s where TeamSTEPPS comes in. It provides you with the skill, the knowledge, and it helps you change that attitude so that your skills actually match your beliefs.

So this is an example of the data that we reported back to our hospitals in 2007 that demonstrated the gap between beliefs and behaviors and what we found was the TeamSTEPPS program to plug that gap. So we were fortunate enough to obtain some funding from the AHRQ Office of Communications and Knowledge Transfer and the Nebraska Rural Hospital Flexibility Program to implement the patient safety practice of teamwork and communications in 25 critical access hospitals, but 24 in Nebraska and one in Iowa.

And our aim is to evaluate the impact of the TeamSTEPPS training program on the safety culture using our rural adapted version of the AHRQ Hospital Survey on Patient Safety Culture. So that’s really where we’re at in terms of our funded program to evaluate the impact of TeamSTEPPS in these critical access hospitals using the AHRQ Hospital Survey on Patient Safety Culture.

So we’ll just pause for a moment and see if there are any questions so far before we actually get into the nuts and bolts of what we’ve done here in Nebraska.

Cori White: I don’t see any through LiveMeeting and I’m not aware of any that have come through on the telephone. Again if you have a question on the phone, I believe you press 1-4 I think the operator said at the beginning. So I guess you can move on.

Katherine Jones: Thank you.

So here is a slide that sort of summarizes our timeline for our implementation. So in March of 2007 as part of our original project that focused on improving voluntary medication error reporting we conducted the Hospital Survey on Patient Safety Culture which identified for us our need for teamwork skills.

In March 2008 then we were able to begin our readiness assessment. It took us a year to obtain the funding from the AHRQ Knowledge Transfer Program and put together our plan for the TeamSTEPPS training. By March 2008 then we were ready to conduct our readiness assessment and that we’ll talk a little bit more about the details of that.

Then in April we conducted two sessions of TeamSTEPPS train the trainers, the two and a half day courses, we turned out 107 master trainers from 27 hospitals.

From May through September we recognized that it’s quite often for initiatives like TeamSTEPPS to stall, so we conducted bi-monthly conference calls with our community of TeamSTEPPS master trainers just for all of us to stay together as a community and share our successes and our challenges.

And then in October just three weeks ago we got together in a central location in the state and we conducted a fundamental course. What we found was that people wanted to get other folks from their organization trained in that sort of boot camp atmosphere bring together, we brought together a group of 57 additional folks across 17 of the hospitals and we trained another set of coaches on October 6th.

On October 7th master trainers and senior leaders from all of our TeamSTEPPS hospitals came together for our lessons learned conference. Our plan is from November to June of 2009 we’re going to conduct monthly calls, again to keep us all together, create that community feeling, share successes and challenges and then in March 2009 we’re going to reassess with the HSOPS and evaluate the impact of TeamSTEPPS training on the culture of safety.

And our plan is sometime in 2009 to have a dissemination conference to really invite others and share our lessons learned about what we’ve learned. And we hope to also have a presence at the TeamSTEPPS conference in June here in Omaha. So that’s really what our timeline looks like and let’s go on and look at each one of these steps and see exactly what we did and what we’ve learned.

Our readiness assessment really followed the pattern that’s laid out in the TeamSTEPPS binder material. As I said we started with the safety culture survey, that was our first item, the HSOPS safety culture survey. And then we really conducted a site assessment with these hospitals. We gave them some homework and that’s one of the handouts that we have for you and we’ll talk a little bit about the detail that’s in that site assessment.

We also had them think about other data and measures they have. We asked them to identify their top three patient safety concerns which are typically including falls and medication errors. We asked them to think about their core measures and where they are on those core measures and put all that information together in one document.

So one document, this site assessment document that we have them complete contains a summary of their safety culture survey data, their core measure data, their medication error data that they have form our previous project.

And we look at all of that data together and we want them to ask the question are they ready and that readiness really considers what structures they have in place to support a reporting culture, what structures they have in place to support a just culture. What structures they have in place to become a learning organization.

We want them to think about that infrastructure for a culture of safety because TeamSTEPPS is just one of the four components of a safe culture and if you listened in on Webinar four that’s what we really discuss is those four components of a safe culture.

So to answer the question are you ready for TeamSTEPPS training, you’ve got to think about what your efforts are to support systematic error reporting, just culture and organizational learning. Are you adept at conducting root cause analysis, aggregate root cause analysis and leadership walk-arounds those basic practices that support organizational learning?

And then we wanted senior leadership to sign on the dotted line that they knew what they were getting into so the senior leadership had to sign a letter of support that really indicated that they acknowledged that they were going to send an interdisciplinary team to the TeamSTEPPS master trainer course. They were going to allow this team to have time and resources to implement team training.

They were already committing to conducting the HSOPS in March 2009, so we needed this commitment from senior leadership. So our readiness assessment really consisted of those five elements, the HSOPS, that site assessment tool, getting together your information on data and measures, considering your infrastructure for supporting of cultures safety and then finally getting that administrator to really sign on the dotted line indicating their support.

So the readiness assessment is one of the documents that we shared with you and it consists of putting down on paper what all of your impending changes and initiatives consist of and some of those changes and initiatives might include the change or a change in your executive leadership, a change in your medical staff, a change in your director of nursing, adding new patient care services, hospital renovations and building projects.

Many of our critical access hospitals their physical plant is aging considerably, they were built under the Hill Burton Act in the ‘50s and ‘60s and their physical plant is aging and very many of our critical access hospitals now are engaging in building programs.

All right, is there an impending regulatory agency site visit? Do you have any other hospital-wide mandatory training; I mean there’s a lot of work here in the heartland focusing on disaster planning. Any other quality initiatives, major technology changes, many of these hospitals are implementing automated dispensing systems, barcode medication administration systems, and of course the ubiquitous electronic medical records.

So all of these things are really opportunities to tie TeamSTEPPS to support another change or initiative. We want them to think about their mission, their vision, their values, their strategic goals and where does TeamSTEPPS fit in with supporting that. We want them to think about any other previous team training experiences and identify what the successes or not successes that were that came out of that and why you weren’t successful in a previous team training program.

A lot of our hospitals have bought into Quint Studor and the Studor group’s five pillars and we want to make sure they tie TeamSTEPPS to that so that all of their initiatives are tied together. Looking at patient satisfaction surveys and employee satisfaction surveys oftentimes if you look at your comments on your patient satisfaction surveys patients will say things about that they weren’t ready for their discharge. And that represents an opportunity to apply TeamSTEPPS skills to the discharge process.

We want them to put down their HSOPS results. We want them to think about data collection, all those other top three patient safety issues which are typically files, medication, errors, and healthcare acquired infections and then we also want them to put down data that they know about their core measures.

You know here in Nebraska we know that for example with heart failure we know that 53% of the time our patients are getting discharge instructions for heart failure. That represents an opportunity to apply the TeamSTEPPS skills to a specific problem like improving discharge instructions for heart failure patients.

The readiness assessment really was intended to show our hospitals how to integrate TeamSTEPPS into their existing strengths, weaknesses, opportunities and threats. We wanted them to recognize that TeamSTEPPS was intended to support their, the work they’re already doing and TeamSTEPPS was not intended to occur in isolation.

And to support that we required that they send an interdisciplinary team to the train the trainer sessions so that interdisciplinary team that they had to send to our train the trainer sessions was to include at least one senior leader who should’ve been their CEO, their CFO or their Director of Nursing and then they had to send front line clinical workers and those front line clinical workers typically included a nurse and somebody from at least one additional clinical area.

And if they wanted to send somebody from a non-clinical area that was fine too, we had folks that came from maintenance, we had folks that came from the front office, but it had to be somebody outside of nursing because we wanted to create this model that TeamSTEPPS training interdisciplinary and we wanted to model that from the get go with the folks that they sent to the master trainer training session.

Once they got to the TeamSTEPPS train the trainer session the first thing we had them do as they came in was create this pre-training survey so that we could give them some immediate feedback during the training session about the needs for TeamSTEPPS training skills. Another thing that we did was the coaching scenarios that are included in the TeamSTEPPS information in the binder we customized those so that they would reflect the critical access hospital environment.

A lot of the coaching scenarios reflect an academic medical center environment or a very large urban facility that includes references to residents and we simply, that doesn’t reflect our environment.

Then a key part of the planning for change part that takes place on the second day of TeamSTEPPS training the implementation planning phase is where we guide them through linking their site assessment data to their SWOT analysis and to an action plan. And again, you’ve got the handout for our site assessment and you’ve also got our handout that we use to help them walk through an action plan.

Many of you when you attended your train the trainer session at the team resource centers didn’t make you actually write an action plan. And our hospitals when they left the train the trainer sessions had to have that three-page action plan completed. So I had to give them something that would make it easy for them to come up with an action plan.

And part of that action plan is being able to boil down your plan to an elevator speech that you can communicate to others. So that’s what they had to communicate to us at the end of the day was their elevator speech. And of course we gave out prizes for those with the best elevator speech.

We let them do their teach backs however they wanted to do it, they could do their teach backs in their hospital teams because we recognize that many of these front line folks were not used to presenting formally using Powerpoint. We have one of our critical access hospitals who sent their folks from their long-term care facility and so we had a CNA who was training to be a master trainer and we wanted her to feel comfortable doing the teach back in a way that she would do it back in her facility.

So their teach back consisted of a skit and it was very effective. We gave them some tools to follow-up their training and this was one of these tools were talking points that they could distribute to their medical staff and their board and then a sample press release.

One of the great things in these small communities is that these folks that attended the train the trainers sessions were master trainers and we wanted to give them a press release that they could distribute to their local newspaper about the fact that they had conducted this training.

This was an investment in their people, an investment in their community and that they were really leaders and that’s what this sample press release was intended to convey.

This slide is an example of the pre-training survey. So the Y axis demonstrates the Likert scale that we use. So one, a rank of one was strongly disagree with the statement and a rank of five was strongly agree with the statement.

So if you look at this second item here that says our physicians, nurses, staff and other team members work together as a well coordinated team. What you see with the purple line is that about, that the majority of those responding yes who provide direct patient care that those providing direct patient care tended to be neutral on that item.

And what you see here teamwork deserves more attention in healthcare that nearly everybody was strongly agreeing that that is true.

So this set the stage that those providing direct patient care are indicating that we do not work together as a well-coordinated team.

The next slide was something that we really used as evidence for the need for TeamSTEPPS skills and the need for structured communication. So if you look at the second item, have you ever worked in a healthcare team where there was no clearly designated leader, 68% of those who provided direct patient care said yes. They had worked in a team that did not have a clearly designated leader.

Have you ever worked in a healthcare team where you did not feel comfortable voicing your professional opinion? 75% of those who provide direct patient care indicated yes. And the one, the item in the middle, have you ever felt pressure to perform a procedure that you felt uncomfortable doing? Fifty percent of those providing direct patient care indicated yes.

So you can see how these pre-training surveys set the stage for people to recognize the need for these skills to speak up to those with more authority. My colleague crunches the data in the morning and by lunch of the first day when we do training she feeds this information back to them.

And then we distribute these results back so folks can go back to their hospital with this data to prove that they need some skills to make it psychologically safe to speak up.

So I’m going to stop here again and ask if there are any questions about the site assessment, how we demonstrate whether you’re ready or not for TeamSTEPPS training, and then how we structured our train the trainers sessions.

Cori White: Again, if you have questions about those please type them in under the Q&A tab at the top of your screen or if you’re not connected to Live Meetings you can press 1-4 to indicate to the operator that you have a question. I’m going to go ahead and go back to the two questions that were received through Live Meeting so far. They did come in a little bit earlier.

One question is what is the reasonable gap between the items of belief and items of skill that you would deem acceptable to measure success?

Katherine Jones: The best way to measure success is when you look at HSOPS results over time. So I can tell you if I go back, if I go back to this slide for example, I know that in this organization that I’m looking at here in 2005 staff feel free to question the decisions or actions of those with more authority instead of that being 50% it was about, it was 14% for those nurses. So success was improving from 14 to 50% and that was without the specific skills that TeamSTEPPS has to offer.

So we made success based on giving them a language to talk about error in the context of their system but we still have a ways to go. So I would say that our success in 2009 is going to be based on narrowing that gap even further. What would be an acceptable gap would really be not defined by what’s going on so much in the survey as what are, if you ask people how they speak up if they see something that may negatively effect patient care, and they can give you a scale.

I’m suspecting that there will always be a little bit of a gap between the belief and the behavior, but you would like it to not be as great at 25%. Now I don’t know that I want to say oh, a specific number, 10%, but again I think that the success is going to be best measured by continually closing that gap over time.

Cori White: Okay. The next question, this one’s actually a two part question. It says, at the fundamental training did you emphasize assertiveness for the coaches and were the hospitals compensated for attending the training?

Katherine Jones: What we emphasized in coaching is basically if you take your coaching feedback form that’s in the TeamSTEPPS binder what we emphasize for coaches were basically if you, when you do the coaching module in TeamSTEPPS you end up saying the same thing over and over, which is be a role model and get feedback.

So be a role model by using TeamSTEPPS skills yourself and when you catch others using TeamSTEPPS skills, and they don’t even know they’re using them, label it as a TeamSTEPPS skills and give them feedback.

And the other thing we really emphasize in the coaching part is using the feedback form. The coaching feedback form says that you have to establish a relationship with the person that you’re getting feedback to, you have to focus on performance, you have to communicate instructions and you have to give them some idea how to execute.

But what we found is that the most important thing is establishing the relationship with the person that you’re giving feedback to.

So we, I think that the question was framed in terms of giving coaches confidence, so we try to do that by giving them that three-pronged message which is be a role model, label the TeamSTEPPS skills and give feedback when you see people doing the skills and use the feedback form and specifically build relationships.

When you want to give feedback the first thing you say to that person is how important they are to what you’re doing and how can you help them to be part of the team and achieve the goal of providing safe care. Were the hospitals compensated? No.

What we have here in Nebraska is a situation where when we take the training to them which we always go you know, we always do the training in two locations in the state, one on the East side and one sort of West Central.

And when they have an opportunity to get what I want to call excellent training, when they have the opportunity to be part of a national program and we provide that opportunity for them you know, we don’t compensate them.

They were paid, it was, they were paid by their hospitals just like they would be paid every day, but we didn’t pay them anything extra. We didn’t charge them to come to the program, but we didn’t pay them anything extra.

Cori White: Okay. One last question here that’s come in, and this participant asks if you would be willing to share the coaching scenarios customized to the critical aspect hospital environments through the TeamSTEPPS list serve.

Katherine Jones: Sure. Of course.

Cori White: All right. Thank you. That’s all we have now.

Katherine Jones: And we’re always looking to add to our library of scenarios. We’re especially I want to include some that involve non-clinical departments. Okay well...

Operator: We have a question from the line of Patricia.

Patricia: Yes. I’d like to ask if we could obtain the slides. We were unable to connect to the live connection.

Cori White: If you send an e-mail to either teamsteppswebinars@air.org or cwhite@air.org I’ll pass them on to you.

Patricia Smith: Thank you.

Operator: We have no other questions.

Katherine Jones: So speaking of the coaching scenarios here’s one we came up with, I do, I sort of function as an itinerate root cause analysis facilitator in the state and what I found is that so many times these hospitals have surgeons that come into their hospital from the big city, and so they have multiple different surgeons coming into their organization that they really have no control over. And I’ve tried to convey to them that it’s their hospital, they have to set the ground rules.

So this scenario is one that sort of puts together a lot of information I’ve found out over conducting root cause analysis across the state.

So the operating room is quiet. A new specialist introduces himself to the team. He’s an orthopedic surgeon who’s just started operating in your hospital one day each month. The lead OR nurse calls for the time out procedure. The surgeon starts shouting out orders and insisting that he doesn’t have time for that and it isn’t necessary in this small hospital. The procedure goes smoothly but the team is not happy. At the conclusion of the procedure the lead OR nurse approaches the surgeon to discuss what happened.

Well first of all the first time I conducted a TeamSTEPPS training class what I found was that my folks needed more guidance with the coaching scenarios. I needed to specifically lay out for them what the coaching task was so that they would have a more structured way to interact with the scenario so on each of our scenarios I identify a coaching task.

The coach is the lead OR nurse. How can that nurse resolve the conflict with the surgeon and set the stage for successful teamwork in the OR that improves patient safety?

So first of all the first word that they should pick up on here is conflict. So how do we make this a conflict about information and not about a personal conflict, about power? And of course if we take our coaching feedback form and we zero in on establishing a relationship, that’s the way we coach this.

So the first thing the OR nurse says to the surgeon is how excited they are to have him coming to a pretty good hospital here in small town Nebraska and that this is going to contribute to their ability to serve their community. And she would like to know what they do in the big city to start their OR procedures and how their time out procedure goes, because she knows that time out is a universal protocol.

And the surgeon then has already got his ego massaged by being told that he’s so important to the hospital and the OR nurse has zeroed in on the fact that she knows he’s participating in a time out in the big hospital. And what we end up doing is asking the surgeon to lead the time out in a pretty good hospital in small town Nebraska and creating him as the leader and you know that’s how we coach this.

So we really want to build on all of the tools that TeamSTEPPS has brought to us when we put the coaching scenarios together.

So the next part that I want to talk about a little bit is our action plans. So you have to have in mind the fact that they have completed that site assessment, they have very detailed HSOPS results and they’ve conducted, they’ve put all that through the SWOT analysis.

So they should be ready to define their problems, their challenge, their opportunity and we actually take the first two parts of the action plan and flip-flop them. We want them to define their problem before they create their change team.

And then once they define their problem and identify their change team, they put all that into their specific aims or goals. And in that action plan we give them an example. So the example might be we will use DESC scripts to resolve conflicts across hospital departments.

We’ll start with lab and nursing because their HSOPS results indicated some specific conflict between lab and nursing. These departments will effectively use DESC script by September 1, 2008, so that’s a very succinct example of how they should write their AIM or goal statement.

Then they design their TeamSTEPPS intervention, they think about whether it’s an incremental or a transformational change and we always try to steer them toward an incremental change. They think about the unit or the department of focus, which TeamSTEPPS tools or strategies they’re going to use, they decide on measures that they’re going to use for their, to measure their intervention, are they going to do some observations.

What are they going to count? Are they going to count the number of times a brief, a huddle or a debrief is used? Are they going to count the number of times staff nurses use SBAR? What kind of outcome measures can they look to, for example, rated appropriate preop antibiotic usage? How many near miss reports they obtain the rate of use of discharge instructions for heart failure.

We always tell them, you want your team to start with this outcome measure in mind, that’s your goal, start with the end in mind. This team has been put together to make sure we improve the rate at which heart failure patients receive discharge instructions.

And then of course our ultimate end is the safety culture survey that we’re going to do in March 2009. Which one of those gaps do you want to see narrow? And then we’ve always got our patient and staff satisfaction surveys that we can also look to fill part of our measures.

Step six in their action plan we actually have them identify what they’re going to do and when they’re going to do it. And we have them use TeamSTEPPS tools. So for example, if they want to obtain leadership support from medical staff they can start off with the Sue Sheridan video and then their talking points and also including some of their HSOPS data, the HSOPS data I’ve been told that’s been very dramatic at helping to get buy in from medical staff and boards.

Scheduling training, communicating their aims and goals, conducting the training, in step six they really just need to lay out their plan and decide when they’re going to do what. Not that it isn’t flexible but at least to just get a timeline down as far as what they’re going to do when they’re going to do it.

Katherine Jones: Okay. Great. So we’ll go on to the Aspen plan and then we’ll go back and pick up questions again. We can see step six okay, so everybody we’ll go on.

Step seven ask them to think about their coaching plan, role modeling, monitoring. One of the biggest things about sustaining and spreading the change is simply putting some basic structures in place to integrate TeamSTEPPS into your new employee orientation and your competency testing.

And another big thing is putting a pocket guide in everybody’s pockets. I mean that is where structure meets strategy. People are not going to, if you give them a pocket guide they know you’re serious about using the tools.

Step eight, developing your communication plan. We include a stakeholder analysis in that and the stakeholder analysis is something that comes from six sigma, the change, the coaches and the change acceleration planning and six sigma.

And stakeholder analysis is just a fancy way for saying who do I absolutely need to support this initiative? Who’s probably going to be negative but we need to get them in our camp and who do we know is going to be negative but we can kind of marginalize them or isolate them or ignore them.

You know so you make a very explicit decision about who your stakeholders and who needs to be at the table and how you need to handle each one of them.

Are the communication plan units coming up with that elevator speech? And we make it easy for them. This is exactly what’s on their action plan and it’s basically fill in the blank and of course they’re free to adapt it but I’ll give you an example of an action plan. TeamSTEPPS is an evidence-based team training on elevator speech. TeamSTEPPS is an evidence-based team training program.

We have chosen to focus on communication. It’s important that we improve our teamwork skills in communication because a recent root cause analysis demonstrated that lack of teamwork and poor communication skills adversely affected a patient’s care. We need you to support our efforts by attending training, practicing the skills and coaching others whenever possible.

So that was just an example of a very specific action plan that was actually like the third generation action plan for this hospital. They started using the three-page action plan worksheet as a part of their root cause analysis.

So step nine and ten are the final steps, writing the final action plan and then reviewing the plan. But it’s all in a three-page worksheet. It’s basically, you know, fill in the blank and they emerge from TeamSTEPPS training with that action plan in hand.

So the follow-up that they’re supposed to engage in is taking those talking points to their medical staff, their board of directors, their clinical staff so that everybody knows what’s going on. And it’s basically a one-page handout that describes what TeamSTEPPS training is, why your hospital is participating in it, you’re supposed to provide some data there, what exactly the training entails, it’s two and a half days and then what we need from you.

So for example you’d finish up the talking points to the medical staff with, we need you to support our efforts in team training. Ask us to communicate in a structured fashion. Ask us to give our assessment and our recommendations and give us honest feedback about how our team scales effect the clarify of our communication with you.

So finishing off with what it is, why we’re doing it and what we need from you as talking points. And you can, they can take that one-page document and then customize for whomever it is that they’re talking to. So we give them that tool to follow-up the training with.

Here’s an example of the press release. So Brown County Hospital focuses on teamwork to ensure safe care for patients that was the headline in the local paper. So the press release is given to them and they can sort of customize it. And we encourage them to identify their master trainers by name and that’s always a fun part for the local paper.

The other thing the press release does you know, is it builds an accountability piece in. So now they’ve told their community that they’re doing this and I think it helps them to kind of create that contract with the community that they’ve implemented this program and they need to see it through.

Then our bi-monthly follow-up calls that we hold, we have a standard agenda. We do a roll call to find out who’s on the call and then we use TeamSTEPPS language in the agenda. We close the loop on previous tasks that we’ve discussed. For example, how are we going to order our pocket guides? How are we going to share the training scenarios or the coaching scenarios? We like to share the little funny videos back and forth that we all like to use in the training.

Then we do informal de-briefs from the community. So hospitals will report to us things that are going well and this is an example, this hospital used the magic wand exercise to introduce TeamSTEPPS to surgery and they found that using the magic wand they found that the greatest concerns were how the surgery folks communicate with other departments.

So the magic wand would be, if you had a magic wand and could improve one thing about patient care what would it be? So the folks in surgery said we’d like to have better communication with the other departments. So the exercise provided them with feedback that was far richer than they expected. Another thing they did was implement a comment box that said did you cuss today.

So employees were invited to drop a little note in the box if they cussed today, meaning did you use the two challenges rule, I’m concerned, I’m uncomfortable. Or to drop something in there on how they could have used it but they didn’t.

Then in our calls we have a huddle, so basically the huddle is for us to develop and share tools where intercity and tools to monitor and track our use of TeamSTEPPS skills then we might if we have time we discuss a teamwork related article.

For example we discussed this article on managing disruptive physician behavior and then we do a brief where we planned for future conferences and one of the main things that we discovered was this universal interest in disruptive behavior and so that became a theme for our lessons learned conference.

So that’s what our bi-monthly follow-up calls look like.

And I’m going to stop now and I’m going to back and try to see if I can capture these questions.

Katherine Jones: Oh I’ve got it now, thank you. Sue’s question, in the scenario and the coaching solution what was the key reason for the change in the mindset of the orthopedic surgeon?

Sue what we’ve always found is that if you approach somebody about their behavior the first thing you want to do is establish that relationship. So when we clearly identified to him that we wanted to see him as a leader then he approached us from that leadership position and we wanted to see him as a leader in patient safety and we wanted to stay away from arguing about who was right and keep it focused on what was right.

He does the time out in the big hospital so we expect him to be the leader in the time out in pretty good hospital in small town Nebraska.

So the key to changing his mindset was approaching him as how we wanted him to be, a leader in patient safety, not how he was behaving which was as a prima-donna.

So the next question, okay I’m not seeing any other questions I’m just seeing what people came back to me with. Oh, here’s another question, from Chrissy. What proportion of doctors were involved in the training and how did hospitals engage doctors that were not employed by this hospital? Example, a doctor that admits to the hospital but are not paid to be involved in care.

Chrissy I’m going to be very transparent to you and I’m going to tell you that of the 107 folks that we have trained, well I’m going to up that to including our coaches so we’ve got 164 that are either trainers or coaches, two of them have been physicians. Now these are physicians in small towns that took a day away from their practice to come to the coaching training. So we felt lucky to even get those two.

So how do we engage doctors that are not employed by the hospital? Virtually none of them are employed by the hospital but what we’re hoping to do is through the talking points what we’re hoping to do is to approach them through their WIIFM, what’s in it for me.

Well what’s in it for them is we want to teach them that through this training we are going to communicate in a structured way that will make care more effective and more efficient. We’re basically going at it through the back door.

I know in North Dakota they have a little bit more money in their program and they are going to actually pay (unintelligible) physicians to do care for physicians so they can attend the training. We’re not that flush here in Nebraska.

Any other questions before we go on?

Operator: Yes. We have the next question is from Barb. Please proceed with your question, your line is open.

Cori White: … I guess not. Are there any other questions on the phone?

Operator: No we have no other questions.

Cori White: Thank you.

Katherine Jones: Okay. We’re closing in on the end here and want to talk a little bit about lessons learned and as I mentioned in our follow-up calls, a theme that emerged quite often in our train the trainer sessions was circling back to how are these tools going to work when we really have a poisonous individual?

So a lot of times we circled back to this idea of disruptive behavior. So disruptive behavior became a theme at our lessons learned conference and our lessons learned conference took place on October 7th at a central location in the state.

We had about 83 folks at the conference and again, we started off with the same approach that we did in our training sessions which we did a quick little survey in the morning, a survey of staff relations that we could provide feedback to during the day, a keynote address was delivered by Alan Rosenstein and Michelle O’Daniel on reporting and management of disruptive behavior.

And Dr. Rosenstein and Ms. O’Daniel have done an extensive amount of research and published in the Joint Commission Journal and other publications on disruptive behavior and we were thrilled to have them come to Kearney, Nebraska to deliver this keynote address to our TeamSTEPPS community.

So after the keynote address we had a little action plan that the hospitals engaged in at their table and then they reported out what their issues were that they were going to address and how they were going to address them including reporting plans and interdisciplinary committees to address behavior and those types of things.

In the afternoon we had our TeamSTEPPS community present story boards and presentations on how their implementation has been going so far. So basically they were sharing what’s going well, what’s not going well and that was our day for our lessons learned conference.

So part of the, I wanted to share just a little bit about the disruptive behavior component and we focused on this definition of disruptive behavior that it’s any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment.

Basically disruptive behavior is anything that makes you walk away and ruminate about that interaction with someone else and you’re thinking about that interaction and you’re not thinking patient care. It’s something that evokes strong psychological and emotional feelings that can adversely affect patient care.

These are results from our staff relation survey that we reported back to the folks at the conference over lunch and what I want you to focus on is that basically 45% of people were either negative or neutral about communications.

So 26% were neutral, meaning that they defined their staff relations as communication is not exceptionally effective nor exceptionally negative. Advocacy and assertion for patients is infrequent and disruptive behavior is infrequent, not reported and ignored. So that’s neutral.

Negative communication was defined as ineffective communication contributing to low staff morale, advocacy and assertion for patients is rare and disruptive behavior is frequent and accepted.

So Bill here is saying he’s unable to download the PDF file, is there an alternate way to access. Anybody have any idea?

Cori White: Yes. If you e-mail teamsteppswebinars@air.org I’ll pass it on.

Katherine Jones: So what we were able to report back to folks at our lessons learned conference immediate feedback was that 45% of people were either negative or neutral about their communication. What’s not shown here on the pie graph is that there were two other categories of behavior which was excellent and abusive. And nobody reported that their staff relations were excellent and nobody reported that they were abusive.

Here’s another example we asked people to report the frequency of the types of disruptive behavior. So we defined frequently as more than three times a year, and you can you know, argue whether that’s a good definition but that’s what we use.

But what you see here are the things that were most often frequently reported was berating colleagues and being disrespectful and being condescending. So those are all examples of disruptive behavior.

And then finally what are the things that trigger disruptive behavior because you’ve got to know the antecedent or the trigger for a behavior to really identify what you’re going to target. So you can quickly see here by looking for the purple bars that there are a few top things that trigger disruptive behavior, staffing issues, scheduling issues, horizontal and vertical communications.

One of the things that we were interested to see is that communication between genders wasn’t as frequent a trigger as we thought it might be. It did happen sometimes you know, however, so recognizing how communication differs between somebody who’s a baby boomer and somebody who’s a millennial or a Gen X or a Gen Y person. And we recognized that those need to be looked at in the context of cultural competency and not that one group is wrong and one group is right. And that was one of the themes of the keynote speech by Dr. Rosenstein and Ms. O’Daniel was that idea of conflict originating between generations.

So basically our lessons learned conference looked at disruptive behavior identifying that old frame of reference that we’re just going to tolerate it as the way of doing business, shrug it off, it’s a minor occurrence. It doesn’t have any ill effect on patients or staff. So we’re going to change that to the new frame of reference that disruptive behavior has a profound effect on safety and quality.

And most profoundly for us in critical access hospitals is not to single out physicians but to recognize that disruptive behavior permeates the organization and it’s quite often nurse to nurse, LPN or RN to LPN, LPN to ward clerk, PT to PTA, that nobody owns the market on disruptive behavior and that we need to address this as something that permeates the organization and that there is one standard for behavior that everybody is held accountable to that walks through the hospital doors.

And with the sentinel event alert that came from the joint commission in July we truly can say that hospitals can no longer take a passive approach to disruptive behaviors. So our strategies to address disruptive behavior, I mean you don’t have to do a huge scientific thing, you can just, we gave our survey of staff relations to everybody that they could use in their organization to raise awareness.

We were going to in our next series of conference calls we’re going to have a community approach to developing policies and procedures which will include a code of behavior, how we construct a confidential reporting system, how are we going to enforce this and we agreed that it needed to be an interdisciplinary staff relations committee.

That nobody should be hauled into the principal’s office about disruptive behavior but that you should discuss this disruptive behavior with this interdisciplinary staff relations committee which makes you accountable to your peers and not just to leadership and follow-up and feedback is going to be prompt to those that report disruptive behavior.

We’re going to do education by linking behavior to adverse events and of course we’re going to put our focus on disruptive behavior in the context of our TeamSTEPPS skills.

So, this slide summarizes our lessons learned about disruptive behavior in the context of our TeamSTEPPS skills. Many of you that have been through the master trainer training know how rich the TeamSTEPPS logo is. And what we felt was that our TeamSTEPPS skills has to be supported by the fact that individuals feel valued in your organization and the fact that individuals are treated with respect.

Individuals operate within teams and so to function effectively you’ve got to get at controlling disruptive behavior. So we wanted to put our TeamSTEPPS skills on this foundation of a strategy to address disruptive behavior. So at the lessons learned conference everybody shared their successes and this slide summarizes some of those successes, which is that your interdisciplinary change team serves as a role model for TeamSTEPPS behaviors. Small rewards can create an interest in the program.

For example, in one of our hospitals everybody that goes to TeamSTEPPS training gets a little goose pin and geese fly in formation and support each other. And so that is just an example, you know, people wanted to go the training because they wanted to get their goose pin. One of our hospitals has t-shirts for everybody with penguins on the back and their hospital name on the front.

One of the common themes was that there are key tools, use SBAR for shift change. Everybody needs to be trained (unintelligible). Huddle, briefs and debriefs are tools that everybody needs to know. Integrating essentials into new employee orientation that the change team is accountable to reporting to the board on their progress. Boy doesn’t that hold you accountable.

Training front line staff as master trainers is very effective and what training front line staff as master trainers has done is it has revealed latent leadership talents within many front line staff. And we’ve had front line staff that have gone on now to be recognized as leaders in patient safety in their organization.

Non-clinical departments are very effective at using TeamSTEPPS tools and what we’ve found is that if you want to achieve transformational change in your organization all clinical staff have to have a fundamental knowledge of the TeamSTEPPS skills and your medical staff and your board have to be given essentials training and a pocket guide. Those were shared successes.

Suggestions include using the magic wand exercise to open a discussion because once you ask somebody if you had a magic wand and could change anything about patient safety in your department what would it be? Then the next thing is which tools can I give you to achieve your dream?

So it’s really a great way to open the discussion, having your change team lead my iceberg is melting has been indicated to be quite successful, integrating TeamSTEPPS tools into RCA action planning.

One of the things we’ve found is giving people multiple formats for SBAR. So for example we’ve customized the assessment part of SBAR for physical therapy to speak to physicians and another unique one that we’ve done is customize the assessment part of SBAR for long-term care to report back to psychiatrists about changes in behavior.

So for example there is a checklist for is the patient having, are they having hallucinations or delusions? Is there a change in their appetite, a change in their sleep pattern? Any suicidal ideation? So we customized that assessment part of SBAR for different disciplines.

Role playing and active learning are critical. You know you can have fun with it and say the Oscar goes to certain people when they do their role playing. Strategy follows structure, so if you’re serious about implementing TeamSTEPPS in your OR, we had one hospital that shut down their OR for an entire day so that all their staff could train together. That sent a very serious message about the importance of TeamSTEPPS skills in that organization.

So what are some unique attributes of our training here in Nebraska? We are a network of hospitals with a four-year history of functioning as a community with a shared purpose to improve our culture of safety. We are data driven. We use our baseline HSOPS results and we have medication error data that we have that’s shared as a community from our reporting to the national medication error reporting program Medmarx.

Our action planning and our TeamSTEPPS training is integrated into that training. Those hospitals lead that two and a half day training with their three-page action plan in hand, their talking points and their elevator speech. Basically TeamSTEPPS here in Nebraska is integrated into action research. Action research is what I do as an academic.

Action research is research with people, it’s not research on people it’s research with people. We are solving real world problems with this research. So our research is imbedded in what they need to do to achieve a culture of safety in their organization.

So those are four which I think are maybe unique points about what we’re doing here in Nebraska. Bur more importantly for you all what are the lessons learned that are kind of universal? Well one of those universal lessons learned is that there’s always a tension between incremental and transformational change and I’m going to talk about that a little bit more on a couple of the last slides.

Finally, use the active learning portions of your TeamSTEPPS curriculum. Opportunities for role playing and exercises, use those in the curriculum and search for all the new active learning opportunities you can, whether it’s role playing or ice breaking scenarios.

Active learning trumps lecture every time. They will leave that training session remembering what they did far more than what they heard. There’s always time to flip back to your pocket guide for the didactics but what you did is going to stick in your mind.

You need to create buy in for the training and two ways to do that is data from the HSOPS and having front line staff as your master trainers. If you put the same old tired folks up there that people are used to in leadership positions all the time, it’s just going to be seen as something else that leaders are telling you to do. But if front line staff is there leading the charge this is going to be recognized as something different. Use rewards, make it fun.

And then finally, the final lesson learned is start with the end in mind. So changing your culture, so starting with the change that you want to see with your HSOPS data, starting with the change that you want to see in your core measures, start with the end in mind. I think that’s another universal lesson learned.

In the couple minutes I have left I want to leave you with this thought about transformational change. So that when you go into TeamSTEPPS training folks usually fall into one of three basic categories, they either want to embrace and absorb the training, they’re skeptical at first but then they connect, or they’re resistant and they’re defensive from the get go.

And one of the reasons for that is that TeamSTEPPS gets at really transforming your belief system. We want to change people from believing in their individual infallibility to believing in the fact that people truly do make fewer errors when they work in teams. But you don’t get there by directly challenging people’s belief systems, you get there by modifying existing behaviors.

So if you focus on modifying existing behaviors, we all talk to each other anyway, but you know what SBAR might be a better way for us to communicate more effectively. So you can sort of manage that tension between incremental and transformational change by recognizing that if you directly challenge people’s belief systems you’re going to get pushback, but if you start off by just modifying existing behavior you’re going to get more buy in. And then you’re going to move them to that eventual point where they do recognize that working in teams is safer for patients.

So I could talk for an hour and a half just on this slide, but I don’t have that time so I’m going to move on. So our final lesson learned is that to achieve an informed culture of safety we have to create an environment of trust. And that environment of trust is built with TeamSTEPPS which is founded on a foundation of that acknowledgement that individuals must feel valued and individuals are treated with respect.

So to achieve that culture of safety we have to have a reporting culture, a just culture, a flexible teamwork-based culture, and a learning culture.

So with that I’m going to stop and see if there are any other additional questions.

Operator: We have no audio questions.

Cori White: Okay we’ll give you all a few more, a couple minutes or a couple seconds just to think. Again, if you have a question please use the Q&A tab at the top of your Live Meeting window. Or if you’re connected just on the phone you can press 1-4. Again if you need the slides for this Webinar or if you need the handout materials or have any questions about Webinars you can e-mail teamsteppswebinars@air.org and we’ll make sure that you get them.

Operator: We do have one question from the line of Christy. Please proceed with your question.

Christy: I just wondered if doctors were involved in the change team and did they help create the action plans.

Katherine Jones: As I said before we most of our doctors are community doctors and primary care in the community and they were not directly involved in the action plan and typically they are not directly involved in the change team and that’s just because of our environment.

Most of our physicians are just, our staff they’re not employed by the hospital, they practice in the community and they admit patients to the hospital. And you know, that’s just the reality of our situation.

When are the train the trainer sessions and where? Well is that a question for the National Implementation, I think can you give them information about where to access that information on the AIR Web site?

Cori White: Actually if you’re interested in having train the trainer, if you are interested in attending through National Implementation the Web site for TeamSTEPPS is www.ahrq.gov/teamstepps and on there it talks a little bit about the availability of training under the national implementation program and how to get in contact with us if you’re interested in attending the train the trainer sessions. Again that’s AHRQ.gov/teamstepps.

Katherine Jones: You know one of the things that here in Nebraska we weren’t, we’re not directly involved in the National Implementation Project, we kind of use the itinerant preacher approach, if you will. So a couple of folks were initially trained as master trainers such as myself, and then we have taken that out to groups of hospitals so communities of hospitals train together.

Whereas with the National Implementation different hospitals from across the country go to one of the four training sites. So this is really an extension, ours is really an extension of the work that’s begun in the National Implementation and really a way to spread TeamSTEPPS within a state. Any other questions?

Operator: We have no audio questions.

Katherine Jones: The final slide here shows my contact information and since I’ve been kind enough to distribute those handouts to you I would very much appreciate some feedback about what you find useful on those handouts and what you don’t find useful. And if you can figure out a way to improve them, please let me know that as well so we can all be part of the community that’s adding to our tool belt of tools that we use to implement TeamSTEPPS.

Is it time to wrap up Alex? Or do you want to wait a little bit longer for some more questions?

Cori White: Let’s give just another minute for questions before we wrap up and so again, if you have questions you can either use the Q&A tab at the top of your live meeting screen or if you’re connected on the phone you can press 1-4 and the operator will connect you to us.

And while we wait for questions I just want to mention that, if you attended today you’ve probably given us a little bit of contact information or received the log in information from me earlier this week and because we’re having computer problems at AIR we would ordinarily ask for some feedback through Live Meeting but since we don’t have that capability today we may be in contact with you later just with two really, really quick questions about the Webinar today there.

They’re all multiple choice so if we may be in contact with you so hopefully you’ll have a minute.

Katherine Jones: I’ve got a question from Sue about how the Medmarx data was used. One of the key ways the Medmarx data was used Sue was that there are option, in Medmarx there are fields for causes and contributing factors to medication errors and causes of the medication errors include things like not following policy and procedure, contributing factors include things like distractions, workload increase, staff inexperience, shift change.

So you can see how those contributing factors and causes of medication errors identify opportunities for TeamSTEPPS and team skills to address them.

So just like the joint commission’s Sentinel Event Database shows that communication is the root cause of two-thirds of all sentinel events, the Medmarx data shows that lack of communication and teamwork are root causes of medication errors.

Cori White: Okay. I guess if that’s all we have...

Katherine Jones: Oh good grief who got up at 2:30 am to attend?

Cori White: Oh no, it looks like Alex may have been placed on mute so that’s how we got lost. I’d like to, on behalf of Alex and the rest if AIR thank you very much Katherine for speaking and for everyone else for participating and bearing with us through our few technical problems we’ve had today.

And we encourage you to visit the TeamSTEPPS Web site, again AHRQ.gov/teamstepps, there’s a lot of information about future Webinars, past Webinars and the National Implementation Project. You all should have seen our contact information and again that’s in the slides and the handouts.

So if you have any questions please feel free to contact us. We really are excited about this and really happy to help. And so I think that’s all we have for today.

Katherine Jones: Thank you all very much. It was a pleasure to share our journey that we’re on here in Nebraska and hopefully now everybody will locate Nebraska on a map. We’re right in the middle.

Alexander Alonso: Thank you Katherine.

Katherine Jones: Thank you Alex. Have a good day.

Alexander Alonso: Thank you. Bye-bye.

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.