AMERICAN INSTITUTES FOR RESEARCH

National Implementation of TeamSTEPPS Webinar 6

Moderator: Alexander Alonso
December 10, 2008
12:00 pm ET

Operator: Ladies and gentlemen thank you for standing by. Welcome to the Using TeamSTEPPS in Nursing Homes conference call.

During the presentation all participants will be in a listen-only mode. Afterwards we will conduct a question and answer session. At that time if you have a question please press the 1 followed by the 4 on your telephone. If at any time during the conference you need to reach an operator please press star, 0.

As a reminder this conference is being recorded Wednesday, December 10, 2008. I would now like to the conference over to Dr. Alexander Alonso. Please go ahead sir.

Alexander Alonso: Thank you. Good morning and good afternoon to all those of you who were kind enough to join us today. I want to thank you and welcome you to come to the sixth Webinar in the series of the TeamSTEPPS National Implementation Webinars. And today’s Webinar will focus primarily on TeamSTEPPS and nursing home implementation as well as other types of facilities that are similar to nursing homes.

For our Webinar today we have a co-facilitator by the name of Mari Lou Keberly from the Georgia Medical Care Foundation who has been kind enough to join us and share her experiences with TeamSTEPPS in the Georgia nursing homes.

Mari Lou is a team member of the QIO for the State of Georgia; Georgia Medical Care Foundation is the QIO for Georgia. She serves there as an advisor for the Care Transitions Team and is an ad hoc member of the Patient Safety Team for the 9th Scope of Work. Prior to this assignment Mari Lou worked on a CMS contract for reducing hospitalization rates with Georgia home health agencies.

As a registered nurse with a background in both hospital and outpatient environments, Mari Lou notes that the TeamSTEPPS training is a natural fit for healthcare professionals. The opportunity to facilitate this work has been a rewarding experience for her and she’s going to share some of those experiences with us today and we’re quite grateful to have her here to share those experiences with us.

As a reminder we do want to ask you to be considerate of all others while participating in the Webinar. We ask that you please mute your phone to reduce background noise, that you do not put your phone on hold if you have hold music or advertisements and that you remember the conference call is never better than the worst connection on the call.

Today’s agenda will begin with a reminder of who we are, what the National Implementation of TeamSTEPPS project is all about, background on nursing homes in the United States, something about the instance of medical errors in nursing homes, then specifically we’ll go into a case study which is Georgia’s experience with implementing TeamSTEPPS in their nursing homes.

Then we’ll provide an opportunity for questions and share our contact information so that you can contact us regarding future Webinars and/or the TeamSTEPPS National Implementation Program.

As some of you have heard before we represent the American Institutes for Research which is the prime contractor for the National Implementation of TeamSTEPPS Program.

We are a not-for-profit non-partisan DC based research organization with a staff that includes healthcare researchers, health services researchers, nurses, physicians, social and behavioral scientists; no doubt that I am a social and behavioral scientist from those of you that have heard me speak before.

And as far as AIR is concerned our mission is to better society through our research and TeamSTEPPS is a prime example of that.

The National Implementation Project is a project designed by AHRQ and the Department of Defense to create a National infrastructure to support the adoption of TeamSTEPPS.

The primary arms for creating this National infrastructure include the Quality Improvement Organizations under the CMS 9th Scope of Work; Patient Safety Improvement Corps under AHRQ and the VA Project; High Reliability Organization; Partners in the ACTION Network or the ACTION Research Network for AHRQ; academic medical centers and other healthcare professional organizations.

The goal is to spread TeamSTEPPS by creating 1200 new master trainers. As far as the project is concerned we have 4 team resource centers that provide training, these include the University of Minnesota, Creighton University, Duke University and Carilion.

We also have two healthcare organizations, one a former QIO and one a current QIO, that provide support on this project with some of the tasks that we’ve been involved with including Lumetra out in California and the Delmarva Foundation here in Maryland.

And then there are two other organizations that provide a support with the evaluation phase of our work which include Booz Allen Hamilton and the Group for Organizational Effectiveness out of Albany, New York. And then AIR is located in DC as mentioned before.

The title sponsors for the TeamSTEPPS National Implementation Program are the Department of Health and Human Services and the Department of Defense. Now the subagencies that have gone ahead and sponsored this work or have been used to sponsor this work are AHRQ or the Agency for Healthcare Research and Quality and the TRICARE Management Activity and specifically their Healthcare Team Coordination Program.

The AIR team is led by David Baker who is the Project Director and holds a dual appointment with Carilion Clinic and the Virginia Tech Medical School; myself, I’m the Deputy Director for Research and Evaluation; Deborah Milne who is the Deputy Director for Outreach and User Support and all types of contact regarding TeamSTEPPS and communications regarding TeamSTEPPS; Rachel Greenberg who is an administrative assistant and Cori White who you will hear throughout the call who helps us field numerous contacts and emails regarding TeamSTEPPS.

We are an interchangeable team; any one of us can provide you with the necessary information you might seek. Here is our contact information, as you can see we provide emails and telephone numbers. I’ll give you a second here to look at this, however, we will provide this again and it will be available to you in our handouts.

Okay. What I’m going to do now is paint a picture regarding nursing homes in the United States. And I’m going to look at some figures back from 1999 provided by the Centers for Disease Control and then I’m going to paint the picture in a more recent time and see how medical error and issues of patient safety have affected nursing homes as a whole.

As of 1999 there were approximately 18,000 nursing homes nationwide with nearly two million beds in them. The number of current residents at that point was 1.6 million and the average length of stay was about 892 days. The number of discharged residents were about 2.5 and the average length of stay for discharged residents was 272 days. The occupancy rate as you can see was about 87%.

In 2004 there were on average about 40 certified nursing assistants per every 100 resident beds. The number of registered nurses and licensed practical nurses were significantly lower at 7 per every 100 resident beds and 13 per every 100 resident beds in 2005. In April of 2005 there was a total of 16,094 nursing homes across the United States. So you can see that that number dwindled heavily and there was a staffing shortage throughout the United States especially for nurses, something that is not unknown to us all here.

Now when we think about the nursing homes and the services that they offer it’s clear that the majority of them offer nursing by registered nurses, nursing aides and nursing assistants as well as physical therapy, occupational therapy, speech therapy, social work and mental healthcare, recreational therapy and room and board.

But this is a largely nurse dependent organization or facility and it is something that was hurt greatly by the staffing shortage for nurses as well as some of the unintended teamwork effects that that had on communication within the nursing homes and the care for the patients. Specifically the safety culture was affected by the staffing shortage and/or by a great deal of the changes in nursing homes over the last decade.

Typically it was noted as far as AHRQ’s Nursing Home Culture Survey that - not their new Nursing Home Culture Survey but their previous Nursing - that the AHRQ HSOPS Survey using nursing home benchmarks it was noted that they were typically lower than hospital benchmarks.

Because of that AHRQ released and modified the HSOPS contextualized specifically for nursing homes which is available at this link here below. Along with that you’ll also find that there is information about the benchmarks and the database report for nursing homes.

Safety culture tended to be a problem because of high staff turnover and because of poor communications during transitions in care because of this turnover. Residents of nursing homes were seen as being at risk of harm as a result of patient safety errors.

Recent studies of patient safety in nursing homes have highlighted major concerns about staff perceptions of the following: patient safety practices; retaliatory practices that undermine just culture; breakdowns in information exchange; and breakdowns in hand-offs during transitions in care.

Additionally recent studies and these are recent studies as of 2008 have pointed to potential medical errors that result from these breakdowns in communication or breakdowns in interactions. These - those include pressure ulcers which I’m sure many of you are familiar with; operative and post-operative complications; medication errors; delays in treatment; and patient falls. As we all know these errors are preventable.

So what does this mean for TeamSTEPPS and nursing homes? Well we know that TeamSTEPPS is a culture change initiative and is specifically geared towards changing patient safety culture through teamwork and the lessons learned and best practices for teamwork. As a result TeamSTEPPS is an intervention that could be used to really mitigate the probability of these medical errors by changing the patient safety culture in nursing homes.

Today what we’re going to do is provide you with an example of a project that’s going on with the Georgia QIO, the Georgia Medical Care Foundation. Mari Lou Keberly is going to provide you with a great deal of background on what they’re doing in Georgia to implement TeamSTEPPS in their nursing homes.

The goal of that project is to prevent medical errors resulting from poor patient safety practices and as such they’re working on a patient safety culture change initiative using TeamSTEPPS.

Before we turn it over to Mari Lou which would be next, I’m going to ask that Cori you explain the question and answer session as well as the menu of available options in the software.

Cori White: Hi, I’d be glad to. So in Microsoft Live Meeting which we’re using to facilitate today you have the option to ask questions. Due to the nature of our teleconferencing we are going to ask that you primarily ask questions through the Live Meeting.

So if you’re in Live Meeting at the top of your screen there should be a dropdown menu tab that’s titled Q&A and you can go in there to enter your questions and we will answer them there. Or, often questions are helpful for the entire group and so we will take some designated times and make sure that those questions are addressed for everyone.

Another option that we have in Live Meeting is to distribute handouts and we’ve created handouts with the slides. People seem to like to have those. And so that would be at the top right of your screen and there’s a little icon that looks like three sorts of pieces of paper together. And if you click on that, it allows you to download the PDF format of this slideshow that we’re using today.

The other option that you’ll see at the top right of your screen is a dropdown menu titled Feedback and right now it should have a little green square next to it that says - if you drop down it says Proceed and that’s a good way to let us know how you’re feeling about the Webinar. You can tell us that we need to slow down or you can’t hear. However, if you have a question we ask that you don’t use the little purple one that says Question, we ask you enter it through the Q&A tab.

The other way you can ask a question is as the operator said at the beginning is press 1 and then 4 on your phone and you’ll be put into the queue for questions. Those are the major things that you need to know about Live Meeting. The biggest deal for us is the questions and answers. And other than that that should be what you need to know.

Alexander Alonso: Okay Cori, thank you very much. And I will remind you that later on as we go through the presentation we will stop and provide you with opportunities to ask questions but you feel free to type in your questions in the Q&A box. Also we if you are not using the software you can summon the operator to ask your question and they will let you ask that question at the allotted Q&A session.

We will also do some polling afterwards to get your reactions to the Webinar. But before we do all of that I’m going to turn it over to Mari Lou and thank her for agreeing to be here today.

Mari Lou.

Mari Lou Keberly: Thank you, Alex. Hello everyone, good afternoon. It’s a rainy day here in Georgia. We have some work to share with you on what we’ve been doing in Georgia nursing homes and I’m pleased to be here representing GMCF and the work that is currently underway. I’d like to thank the AIR team of course and the TeamSTEPPS sponsors for bringing this work to us.

As a nurse and quality improvement advisor I’ve seen the issues in healthcare firsthand. We have long been challenged by a rapidly changing healthcare system to find better means of working together towards the common interest of the patient.

As Alex has said, GMCF is the QIO for Georgia and we were invited to participate in TeamSTEPPS as part of our 9th Scope of Work contract. We have several areas of focus here including beneficiary protections, preventions, care coordinations, diabetes disparities, chronic kidney disease and patient safety.

The initiatives in the nursing homes as you can see are on pressure ulcer care and prevention, reducing the use of physical safety restraints and assisting specific nursing homes in need. They are a special focus group. So I’d like to talk to you today about these projects that we’re doing particularly in nursing homes.

First I’d like to tell you a little something about the GMCF team. Two of the master trainers attended the Minnesota sessions in May of 2008 and I am fortunate today to have representatives here at the table. Tracy Rutland is our Education Specialist and he is our other master trainer. When we came back from our TeamSTEPPS training our QIO director Linda Kluge encouraged us to spread this work to other members of the team.

We felt if very important as we approached this work to look at the experts so we included two nursing home experts, Carolyn Roper and Gaetane Wilder are very familiar with our nursing home groups and have worked with them for several years. We have hospital coordinators, two other patient safety coordinators and a lead communication specialist. She helps us a lot in capturing the essence of the meetings and with audio and visual support and she’s an integral part of our post meeting debriefs.

This template for change is very familiar to us here at the QIO. We followed the footprints laid out in TeamSTEPPS as we developed our plan. I’ll next show you how we set the stage, decided what to do, our ongoing plan for making it happen and our creative ideas for making it stick.

We naturally included data to set the stage for the program. Looking at the past two years we could see improvements in both areas for nursing homes but we knew that there were still gains that we could make. We needed to take a closer look at the barriers in long-term care, how could we help create change that would be meaningful to the long-term care providers and create a sense of urgency about the improvements.

One such step for instance when demonstrating the data graphs often I hear the nursing home consultants speak to the participants about the residents on the units attaching a true face to a name to think about what’s happening in the facility and how it contributes to the State averages. They create a mental picture of how they can contribute to the change one resident at a time.

Next we needed to decide what to do. We did an internal SWOT Analysis to uncover our best opportunities and as we noted in the introduction the issues in nursing homes are many: high risk residents; staffing turnover: reimbursement issues. Our consultants knew a lot about this. We looked hard at the work that had been done so far.

We wanted to utilize the new TeamSTEPPS concept but incorporate them into materials that were familiar to the long-term care providers. We needed the intervention to be meaningful and speak to the heart of the problem that these caregivers face everyday.

One strength of course was the successes that we’ve had in the past. We considered the evaluations from past meetings and we drew on these experiences. Some of the homes had been involved in cross setting meetings for instance. These are smaller community groups of long-term care, hospital and home health agency providers that meet throughout the State. They had worked towards improving communications on patient transfers. We thought of ways to incorporate the lessons learned from these sessions.

We knew that it would be important to reach our audience and we have some great stakeholders in Georgia. The Georgia Healthcare Association is a nursing home group, and most of our nursing homes are members and there are fall and spring regional council meetings that we typically participate in. Because this scope of work had changed and we have some particular participant groups in nursing homes that we need to reach, we included them of course in these fall council meetings. And these occurred in October of this year.

We offered CEUs for the administrators to help draw them in and we linked the TeamSTEPPS framework to the quality improvement measures that we are contracted to work on. The lure of teambuilding proved effective as registration grew. 134 individuals participated representing 54 long-term care facilities.

As you can see what we offered for leadership, teambuilding, collaboration and communication and particularly the active sessions - the interactive sessions we thought were a real draw for our participating groups.

Are there any questions so far?

Cori White: It looks like we don’t have any through Live Meeting. Again we ask that if you have questions you go to the top of your screen in the Live Meeting program and click on the Q&A tab. Operator do we have any questions through the phone system?

Operator: Not presently. But ladies and gentlemen if you’d like to register a question please press the 1 followed by the 4 on your telephone. You will hear a three tone prompt acknowledging your request. If your question has been answered and you’d like to withdraw your registration, please press the 1 followed by the 3.

Cori White: Thank you.

Mari Lou Keberly: Very good. Thank you all very much.

Next we needed to look at how to make this whole process happen. Our main goal in these meetings was to provide a doorway to a better understanding of how TeamSTEPPS could enhance the current work. We began with teambuilding concepts for both leadership and staff. We wanted to demonstrate the gains that could be made through better collaboration.

You might be familiar with this icebreaker from TeamSTEPPS. It’s in the manual. For our icebreaker we broke the participants into small groups. We used the three phases of the building a paper chain exercise to get them engaged. It seems so simple but it did get them talking and participating. We debriefed (unintelligible) building on the concepts of team structure and communication. We also were able to discuss a lot in this session on barriers to effective teamwork.

If you’d like, we have a short live video of what this looked like in our meetings and I think it helps to better demonstrate what we were trying to accomplish by setting the stage, making it happen and creating a very active session for growing the TeamSTEPPS work. Alex can we play that?

Now the video is a little darker than we had planned and the music wasn’t attached to it but in our sessions this came across very well and was very lively. So we think an icebreaker piece is very important.

This is a familiar slide if you’ve worked on the TeamSTEPPS material. And our participants really identified with the “Why Errors Occur.” We opened up discussion and encouraged the participants to discuss the barriers. They really identified with many of these causes and could share stories of how these events can lead to errors and patient safety issues.

We heard their frustrations in dealing with communication breakdown with physicians, patients, families and often with each other. This was a good building block to better understand what was occurring in their environment. We found that they wanted real solutions and opportunities for learning how to create better steps within their facilities.

Introducing the TeamSTEPPS framework and helping them to see the possibilities for improvement was the next step. We had just three hours at these first meetings and thought it best to select portions from within each of the skill sets and help them to understand how to best utilize the tools.

We used a variety of strategies to get ideas flowing. We talked about how teamwork has helped other organizations and how applying these principles in healthcare could be used to improve their daily routines. For me as a nurse it seemed a natural fit for healthcare to adopt this model.

This is Carolyn Roper one of the facilitators and Carolyn is excellent at getting them talking. We really worked hard at keeping the participants engaged in lively activities and discussions.

As the meetings evolved across that State we discovered that the interactions ranked high among the participants. Everyone had stories to share. We found that they were thirsty for knowledge on how to work better together.

We used avenues in meetings that probably most of you are familiar with. We did SWOT Analysis specific to the facility, talked about root cause events and how to monitor for that and we talked about group versus team activities. From here we moved quickly into the TeamSTEPPS concept of situation awareness, situation monitoring and mutual support.

We had received the book Our Iceberg is Melting by John Kotter at our master training sessions but since our initial participants had not we had to tie the pieces together a little differently. These concepts from the Heart of Change naturally emerged as we moved forward.

It wasn’t until later that I realized that our team of facilitators had so readily done by helping the facilities visualize the problems, they used the Sue Sheridan video which is in the TeamSTEPPS materials and another video that we’ve used in a past scope of work, Look At Me on patient directed care principles.

The Look At Me video and the mystery game were adopted from earlier work on the Person Directed Care Model. The video provides an inside view of an elderly person in a long-term care setting. This approach seems particularly engaging to the nursing home groups as they could readily identify with the storyline.

In the mystery game if you’re not familiar small workgroups use a set of preprinted cards. Each card holds a short statement about an imaginary resident and when shared create a storyline. As the participants share their cards they paint a picture of the individual. We would then open dialogue on a shared mental model, mutual support, task assistance and the importance of collaboration and communication.

Using these tools helped to create a powerful message for how teamwork can change and improve the daily delivery of care. This helps to bring that emotional response that John Kotter talks about and also helps charge up ideas to help change behavior.

An example of the cards for instance on one particular card it talks about a resident whose wife died a while back and how that might impact the care. Another card talks about a patient being a night owl and his skills sets would be different. The team would need to know information about that. And tying this to ways to communicate within the team was very important and helped to develop that idea.

We built on their needs. We talked about the barriers, we used the TeamSTEPPS toolbox and we were best able to link the tools and strategies in this way. Though we couldn’t cover all the tools in the first three hour of meetings, we have made progress with the initial implementations. By outlining the outcomes that they can expect to achieve by following this model, we hoped to create a broad base for use within this setting.

This is another strategy that we used and there’s been a lot of talk on the TeamSTEPPS listserv about building scenarios. We have thought of creating live videos in the future. Our first run was in print. We could quickly see the results of what we had taught and the participants were really able to use the tools very quickly within a very short period.

In this example we provided an opportunity for the group to discuss who would be a part of the team, how could they best share the information and we’d ask them to role play the brief checklist.

Of course on this slide I give you a piece of the scenario and I give you the answer. During the learning sessions of course the teams do not have the answer. We’re asked to provide the answer and then role play the checklist.

The providers in long-term care know well how quickly patient situations can change. We built this scenario in stages and asked them to identify the tools and strategies that they would use next. We also invited discussion points on existing barriers and effects of effective versus ineffective teamwork. Of course in this slide they discuss the content of the huddle.

The CUS tools were picked up very readily by our teams. Talking points on advocacy and assertions and a two challenge rule can be used here as well. They were able to role play the CUS tools and we found this piece very effective. And when I talk in a few minutes about the strategies and tools that they liked the best you’ll see that this is one that everyone said was readily adaptable to their settings.

I think another thing that they liked about the tools, these were things that they could use the next day when they went back to the facility. It didn’t have to go through committees in order to think better about patient safety issues and using something that was very straightforward.

Building on communication strategies with both internal and external contacts was another highly sought strategy. We handed out SBAR samples from the Interact Tool Kit. The Interact Tool Kit was used in a special study here in Georgia for reducing hospital readmissions from nursing homes. It’s helpful here to actually walk through the SBAR steps as we often learn best through those experiences.

As we tied the concepts together for brief, huddle and debrief to actual scenarios it helped our group to better understand that they could carry these teachable, learnable skill sets right back to the facility and again use them immediately. This helped to establish the early buy-in that we wanted and adopt desire to learn more.

Do we have any questions about how we proceeded with the scenarios or the strategies that we’ve demonstrated so far?

Cori White: We have someone who says that they’re having trouble with all the slides being displayed. This may be a problem based on security settings. We’ve had trouble with this before. You might want to try downloading the handouts from the top right corner, the icon that looks like three pieces of paper. If not then you can please send an email to teamsteppswebinars@air.org which is the email address that your log-in information should have come from and we’ll send you a copy so you can follow along.

I don’t know if we have any questions on the phone.

Operator: Ladies and gentlemen as a reminder to register for a question please press the 1 followed by the 4 on your telephone.

Cori White: Okay we have another question here from Live Meeting and this question says, “Would you please share the agenda with time allocations from your HCFA program?”

Mari Lou Keberly: We could do that. I don’t have it on my desktop to give to you right now and I almost made that a part of the slide but wasn’t sure that everyone would be interested in that. So we could certainly share that. Cori shall I send that to you?

Cori White: Yes, you can send that to me and then if people want to receive it again they can email teamsteppswebinars@air.org.

We have another question about not being able to print handouts, again if you’d like to have them emailed to you it’s the same email address. Any questions that you have about receiving actual materials can go to teamsteppswebinars@air.org. Thank you.

Alexander Alonso: Cori I do want to correct you on one thing, if folks want materials from Mari Lou or from their program we will direct them to Mari Lou directly. So at the end of the presentation we’ll either provide Mari Lou’s contact information or we can make sure that Mari Lou’s contact information is shared with all the attendees of the program.

Cori White: Okay.

Alexander Alonso: Thank you.

Cori White: Thank you.

Alexander Alonso: Okay Mari Lou.

Mari Lou Keberly: . Are there any other questions to address at this point?

Alexander Alonso: Nope.

Mari Lou Keberly: Okay. Thank you. Yes and the QIO Director is here and very supportive of us helping others as they facilitate in the nursing homes. And so we may be able to set up some sharing issues that way and we’d be happy to share the agenda.

Some of the early successes from our fall kick-off meeting, well our registration was better and so we’re not totally sure if it was the TeamSTEPPS materials or the idea that we were going to work on leadership skills, communication, collaboration but we do feel that that was a part of it. Our satisfaction scores were good for those initial meetings.

And our Education Specialist Tracy had setup the TeamSTEPPS order forms and our participants were provided those at the end of the meeting and we had a great response rate so we were able to get the materials out to the nursing homes in a very straightforward fashion.

All the participants received a printed version of the pocket guide and that was very helpful during the sessions. It gave them something quick to refer to and when we were doing the scenarios they could look in the pocket guide and help to determine what tool from the tool kit they would use.

Some of the feedback that we received, as Alex had mentioned, teambuilding is desired by a lot of people within our world particularly staff and the leadership in the nursing home environments. They found the communication guide to be very beneficial. Resources are essential and this is - these are groups that don’t get a lot of resources and sometimes have difficulty getting materials. So having the AHRQ materials available to them was very important to help bring them to the table on this.

The tools that were most appreciated in the beginning anyway, remember this is a rollout in October so we’re still moving forward on this initiative, but they have liked the brief, huddle and debrief, the CUS tool as I mentioned, SBAR has been very well received and the STEP tool as well for looking at residents and the assessments that are done.

Evaluations were completed at the end of each of these meetings and about a month later a second survey was done and it was a blinded survey that was sent out, a Survey Monkey. It was an online tool. And that helped us to look at how these tools were being used after the initial meetings and we have had good responses there as well.

Some lessons that we’ve learned, we talked about the interactive sessions that they seemed to work the best within this group. The presenters modeling the teams concept was very powerful. I experienced that when we were in Minnesota, the sharing that the teams do while they’re presenting sets a good tone and a very strong message and our TeamSTEPPS trainers have been very supportive in that way and have been able to handoff during the meetings from one member to the other.

The scenarios are very good at creating real work in a real environment. And looking at the responses and debriefing the meetings is essential. For instance after our first meeting we did a debrief and decided another portion would be more effective perhaps and so we changed it up and found out that the follow-up meetings seemed much more interactive and were much more fun for the participants. So we learned as we went and we incorporated everything that we could into the meetings as we grew.

The next thing that happened was almost a bit of a surprise but we felt very positive about it. One of the corporate providers wanted TeamSTEPPS training for all his facilities; so we have since been able to facilitate those meetings. That’s a corporate provider that represents ten homes here in Georgia and those homes, some are on our participant list for nursing homes so that also meets the contract requirements for the QIO.

Nursing homes are talking about receipt of their materials from AHRQ and that they are appreciating that. And more teams are now revisiting the Patient Directed Care Principles which were part of the HATCh model that we taught in the 8th Scope of Work.

In addition the Iceberg is Melting book by John Kotter was sent to our patient safety participating providers and we’re going to facilitate some work on that. I’ll show you how we plan to do that and how we’re going to make this stick in our Georgia homes.

We’re going to support the nursing homes with the TeamSTEPPS concept throughout the 9th Scope of Work. So some of you may know that’s a three-year contract so we plan on continuing to build on this. We continue to look for inroads and open doors for helping providers learn about TeamSTEPPS. With the resource crunch we must work hard to incorporate into the work that we’re contracted to do. We’ve begun education and training for leaders in the Eight Steps of Change and we’ll continue to aid nursing home participants as we move through this next three years.

Our next step towards our shift in culture safety for nursing homes will be to integrate the lessons we have learned to help make the TeamSTEPPS actions very real for them. We plan to support them with follow-up training, monthly conference calls have been initiated for work around the TeamSTEPPS concept and we’ll incorporate everything we can toward their quality improvement efforts.

A nursing home in need provider has opened the doors for a monthly onsite meetings and one of our nursing home consultants will be attending those and tying the TeamSTEPPS concept into their quality improvement initiative.

The cross setting meetings for hospitals, nursing homes and home health agencies are an avenue that we will also plan to utilize to disseminate the work. Using the communications strategies and handoff tools would be especially helpful here.

GMCF you may know is one of the 14 QIOs to receive the Care Transitions Contract for reducing 30-day readmission rates. Although this isn’t particularly a nursing home initiative, there are some homes that will be involved in that as well as our hospital providers. This may also provide an opportunity for us to implement the handoff and transition tools.

With that I’d like to open the floor for any last questions that you might have about our plan or the work that we have been able to do so far. I have some other TeamSTEPPS trainers here at the table. One of our nursing home consultants is here and maybe can address any particular issue for that particular provider setting.

Cori White: Okay. The first question that we have is, “How were you funded to do this work with nursing homes?”

Mari Lou Keberly: Well our QIO Director is here but I’ll take that question. It is part of the - we’ve made it part of the Patient Safety Initiative and we’re blending it with the work that we’re contracted to do with the pressure ulcer and safety restraint initiatives.

Cori White: Okay. The second question that we have is, “Who participated in your meetings? Was it all departments or just nursing?”

Mari Lou Keberly: Yeah we had administrators but we did have some leadership buy-in right from the beginning and we were able to provide the CEUs or the Nursing Home Association actually provided the CEUs. We had clinical staff participants, everything from MDS coordinators to, you know, other onsite staff. We had social workers at some of the meetings. I’m getting back-up from the nursing home consultants but they’re not speaking out loud. But they are helping to field the questions so I appreciate that.

Cori White: Okay. The next question we have is, “How did you address releasing staff to participate in this training? So how did you cover their work?”

Mari Lou Keberly: I’m not sure I understand the question. The QIO work or how did they happen to come to the meetings?

Cori White: I’m not sure. Maybe the person who asked this question could clarify a little just through LiveMeeting and we’ll move on to the next and then come back. The next question we have, “Did the participants decide on any measures to evaluate the changes?”

Mari Lou Keberly: Thus far we have not other than to look at our quality improvement measures of course. You know, we’re always tracking and our nursing home consultants help each participating nursing home to track their pressure ulcer measures and their safety restraint measures.

So but as far as evaluating a specific TeamSTEPPS tool tied to that measure I can’t say we’ve developed that in particular. But it’s something that we could think about working on. We’re sending out a Survey Monkey too.

Cori White: Okay. So we have a clarification of the one question. It says, “Staffing shortages make it difficult to train staff. How did you cover this work to train staff in TeamSTEPPS?”

Mari Lou Keberly: Well, you know, at the fall council meetings there are participating groups that are, you know, they’re interested in quality improvement so they’re getting out there. So even though resources are intense they are sending someone to the meetings to learn the work and then draw that back into the organizations.

Also our corporate provider, you know, found that it was really essential to introduce this to their teams so they provided participants and they opened the door for them to come to the meetings and to really work on this aspect.

So I think I understand what you’re saying. With resources how they are, how do you get people involved? I think Tracy has been great at working on creating that sense of urgency within the group and getting that buy-in is really essential.

You make the work important and essential to change efforts for that culture change and let them know that this is a method that if they learn will actually make their homes better, more efficient. Staffing issues will be less of a problem. So I think that’s how we tried to build that work within these groups.

Cori White: Okay. Thank you. The next question is, “Was this training done for your multiple sites at one location?”

Mari Lou Keberly: No they were at eight locations throughout the State. So we traveled in other words. The group of us traveled from one site to another.

Cori White: All right. Again we ask that if you have questions you enter them through Live Meeting under the Q&A tab. There are a few people who are participating just on the phone so are there any phone questions?

Operator: Not presently. But ladies and gentlemen if you’d like to register a question please press the 1 followed by the 4 on your telephone.

Cori White: Okay. We’ve come up with another question on Live Meeting. This question is, “Do you have results?”

Mari Lou Keberly: Do we have our results? We have some results that I shared on the tools and strategies that people had most liked that we did through the - one, the evaluations at the end of each meeting; and secondly, I mentioned that we did a Survey Monkey a month after. So that’s something that we have absorbed internally as a way to monitor our work which is very typical of the QIO. So that information I shared with you.

Alexander Alonso: Mari Lou this is Alex. I’m going to jump in here for a second. And one of the things that I want to kind of ask you is if perhaps you could tell us or give some context as to how - for example one of the issues that I think is a key issue here is readmissions and specifically the concept of transitioning care.

And I know that we have quite a few folks here from hospital systems including DoD hospital systems or health - the military health system and they do a lot of transition between community facilities that are nursing homes or assisted living facilities and their own hospitals and have issues with readmissions and the transitions in care.

And I wondered if you might talk about some of your experiences in Georgia and how specific tools are being targeted for the admissions or the readmissions or the transitions in care, you know, handoffs for transitions in care or perhaps the ‘I PASS the BATON’ checklist or communication protocol. Could you speak to something like that?

Mari Lou Keberly: Sure. We are, you know, I mentioned that we have the Care Transitions Project in Georgia, and though we haven’t rolled this particular piece into that work just yet, that is a portion of our plan. In our cross setting meetings that have always been active throughout the State for the nursing home, hospital and home health agencies, they’ve worked really hard in those meetings to create better dialogue, better communication steps.

Before TeamSTEPPS the nursing home consultants had helped them develop a transfer form for instance that they use among their participating groups. And some of the groups have adopted that. We’ve used SBAR in the past so we’re going to continue to encourage them to improve their handoff communication through using SBAR. We’ve talked about the check-back and why that’s a feasible tool to use for communication in order to close that loop and make sure that you’ve received the information that the sender had sent.

So some of that work has already been done and not labeled as such as a TeamSTEPPS tool, but now we have another bridge to help that to happen. So we can certainly see that using handoff and the ‘I PASS the BATON’ pieces within TeamSTEPPS would be very helpful and we’re going to continue to work towards that.

Alexander Alonso: Okay. Thank you.

Cori White: Okay. We have a couple more questions on Live Meeting. The next one is, “What about improving quality? Did you have any quality improvement results, i.e. reduction in pressure ulcers?”

Mari Lou Keberly: Oh yeah. We’re working on those things. You know, we just started the 9th Scope in August so those are things that we’re working towards and we monitor our results over time. You’re probably familiar that’s what the QIO program does. And so I would say that it’s early to link this particular piece to the actual data, but that’s something that we’ll continue to monitor.

Cori White: Okay. The next question is - and this might relate back to the one you just answered, “Did you use any tools to evaluate participant knowledge pre and post training? Did your staff make onsite visits to observe behaviors after training?”

Mari Lou Keberly: That’s part of our next step plans. And I mentioned that we have a consultant that will be in that particular group. We have a conference call set up so we will have some steps that we can monitor afterwards.

I think I’m most encouraged by the fact that the groups are receiving the material and they’re asking questions. So they really do want to understand more about how this can help make their work better, more efficient. So I’m sure that that will occur over time.

Alexander Alonso: Thank you Mari Lou.

Mari Lou Keberly:Sure.

Alexander Alonso: Cori do we have any other questions? Operator?

Cori White: Not at the moment we don’t.

Operator: We presently don’t have any questions on the audio portion either.

Alexander Alonso: Okay. At this point I’m going to open the floor to the polls and Cori I’m going to ask you to open the polls so that we can ask our participants if they - their thoughts on the Webinar.

Cori White: All right. This is our first question that we have for you and we just want to know if you found the information that was given here useful and we’ll first give you just a couple - a minute or two to respond and then we’ll do the second question and then we’ll come back and you can see the results.

And again if you still have questions, go ahead and add them under the Q&A tab and we’ll address them while people are voting.

Alexander Alonso: If you’re listening on the phone only please don’t hesitate to use the operator to request a question.

Okay Cori let’s go ahead and close the poll.

Cori White: It looks like the voting has slowed so we’ll close it and we’ll put up the second question.

And we’d just like to know if you’d recommend Webinars to other people. This is helpful to ask in planning Webinars and knowing what people are interested in.

Alexander Alonso: Okay.

Cori White: All right. It looks like that slowed down some too so we’re going to close that and we can display the results.

Alexander Alonso: Go ahead and display the results Cori.

Cori White: Yep. So it sounds like most of you would recommend other Webinars and then if we go back to the first question here I will show you the results of this also which is that it seems that most of you found the pretty useful. So thank you very much for your feedback on that.

Alexander Alonso: Cori it looks like we have another question on the Q&A.

Cori White: It says, “We physicians involved in -- were physicians involved in any of these trainings or follow-up activities?”

Mari Lou Keberly: Yes. We had - at a couple of the meetings we had a Medical Director - Medical Directors who attended. Most nursing homes use Medical Directors. We have a lot of Certified Medical Directors in our state and so yes they were present at some of the meetings. You’re right.

Alexander Alonso: Okay.

Cori White: Than you.

Alexander Alonso: Thank you for that question. At this time I’m going to open the floor again for one more question or for questions in general as we have some time before the 1:30 deadline but...

Operator do we have any questions on your end?

Operator: No but I would like to give a final reminder, ladies and gentlemen if you would like to register for a questions please press the 1 followed by the 4 on your telephone.

Alexander Alonso: Okay. At this point Mari Lou what I’d like to do is open the door - the floor for you to provide your contact information for our attendees to contact you should they have any questions about the presentation or your project overall.

Mari Lou Keberly: That’s great. I should have included that on a slide that might have been helpful. My - the first initial my first name M followed by my last name as on the first slide K-E-B-E-R-L-Y @G-M-C-F.ORG. So that’s mkeberly@gmcf.org.

Alexander Alonso: Okay. And once again her name is Mari Lou Keberly. At this point I want to thank everyone for participating today. If there are no further questions I want to put up our contact slide again for any of you who might have questions regarding the TeamSTEPPS National Implementation Project.

As you can see on this slide right here we have five points of contact for the project. These are direct contact as far as phone numbers. You can see that we’re all located in the DoD - in the DC area. My name is Alex Alonso, my email is aalonso@air.org and my phone number is 202-403-5176.

Should you have any questions about TeamSTEPPS and the Webinars we recommend that you contact teamsteppswebinars@air.org.

If you have questions about the TeamSTEPPS National Implemenatation Program we also recommend that you contact teamsteppscontact@air.org.

Should you have questions regarding TeamSTEPPS you can also go to AHRQ’s Web site which is - Cori can you list the AHRQ Website for TeamSTEPPS?

Cori White: Yes the AHRQ Website is www.ahrq.gov/teamstepps. Again that’s www.ahrq.gov/teamstepps.

Alexander Alonso: Okay. I want to thank you all again for your participation and I want to thank Mari Lou and the Georgia team for sharing their experiences with us. It has been extremely enlightening and helpful to see the TeamSTEPPS initiative in action.

If there are no other questions, last second here questions, I’m going to wish you all a very happy Holiday season.

Operator: There are no questions from the audio portion.

Alexander Alonso: All right. Happy Holidays to everyone.

Mari Lou Keberly: Thank you and the best from GMCF as well.

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.