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Alex: There you go Cori
Cori: Okay its all set up to record now
Alex: Okay I just want to go ahead and ask that you go ahead and put mute
on your phone if possible during the meeting so we don’t hear any background conversation
and that everybody gets to enjoy the webinar or at least be able to listen to the
webinar. I don’t know that you will enjoy it as much as I will. But, having said
that I want to wish you all a good morning and welcome you to the first ever TeamSTEPPS
national implementation project webinar. As some of you might know I am Alex Alonso
and I am a senior research scientist at the American Institutes for Research. You
might also know that I have been a part of the TeamSTEPPS development team since
its inception, including having helped design various elements of the conceptive
framework behind the program. For instance if you have seen the team skills triangle
Dave Baker, myself, and others on the team are critical components who lead to that
triangle. Having said that I, today, will serve as your co-faculty with Dr. Julia
Slininger from Lumetra. Julia is a quality improvement specialist who has been supporting
the National Implementation of TeamSTEPPS under this current project. Julia why
don’t you go ahead and introduce yourself to the group.
Julia: Sure I’m glad to do that thanks Alex and the first thing I’ll correct
is I can’t claim that Dr. that you put infront of my name on the slide. I am flattered
but I am not a physician nor a PhD.
Alex: My mistake
Julia: But I am a healthcare consultant with Lumetra, that’s the California
QIO. And we’ve been privileged to work with AIR as Alex said to help with the recruitment
and to introduce TeamSTEPPS across the nation. And I will be an additional resource
for this call and subsequently.
Alex: Thank you Julia. Having said that the topic of today’s webinar is using
TeamSTEPPS to satisfy the requirements of the 9th Scope of Work and to serve your
partner organizations as a quality improvement organization. So as part of today’s
agenda what we’re going to do is review TeamSTEPPS a bit. Which I know for some
of you may be taxing given that some of you are master trainers and have been for
quite some time. Despite that I think it’s important that we go over the elements.
Having said that we are also going to discuss areas of applicability under the 8th
and 9th scope of work, then we’re going to go ahead and discuss what some QIOs can
do, I’m sorry, all QIOs can do in action following training in order to foster TeamSTEPPS
and/or foster TeamSTEPPS initiatives at partner organizations. We’re also going
to provide you with some examples of how QIOs are using TeamSTEPPS to support their
partner organizations and then we’re going to discuss the future of these webinars
in particular. Before we begin I’d like to give you some instructions on the software,
namely about questions and answers, raising your hand if you’d like to go ahead
and ask a question of the group, and polling that we might do throughout the webinar.
If you notice on your software you have a tab at the top menu that says “Q&A”. As
part of this you are entitled to ask questions of the presenter, namely me. If you’d
like to keep this private you do not have to raise your hand, you can go ahead and
type your question in and I will be able to read the question and maintain it anonymous.
If you’d like to ask a question of the group over the phone you can also type in
your question or raise your hand in that same questions and answer box. When you
raise your hand what that does is notifies me and other presenters that you have
a question that you’d like to ask of the whole group. As a second function I’d like
to go ahead and inform you that throughout this process we’re going to go ahead
and poll you as to the usefulness of information provided and the usefulness of
webinars in the future. Polls will pop up in a separate dialogue box and you will
be asked to vote. Go ahead and click your vote and that data will remain confidential
and anonymous with us. Having said that let’s go ahead and begin.
Slide: Patient Safety: The Final Frontier
Today patient safety and reliability are in pair are through reduction of medical
errors remains the major challenge for organizations and providers alike. I think
we’re all in agreement about that. I have to attribute this to our partner David
Snyder of Lumetra when I say you should pardon the pun that patient safety really
remains the final frontier in terms of healthcare organization reliability and it
is the prime frontier for QIOs and quality improvement in particular. To that end
there are multiple fronts by which patient safety can be enhanced among providers.
Examples include changing the system via mistake proofing and other human factors
types interventions. I’m sure many of you are familiar with mistake proofing as
an intervention and may have been given an opportunity AHRQ to attend mistake proofing
conferences hosted by John Grout, for example, of Beck College in Georgia. Having
said that, still human factors interventions cannot remedy the situation alone.
Much of what leads to error entails human interactions which call for interventions
for standardizing interactions as well as improving coordination of actions. As
you know TeamSTEPPS tackles this very front by providing strategies and tools to
enhance human interactions. This program is one of the most comprehensive teamwork
based programs because it provides tools for evaluation and process improvement
and improvement of system behaviors that are grounded in empirical evidence. Simply
put it goes beyond what other programs have provided in the past because it relies
on evidence based research and practice to yield organizational culture changes
rather than just providing basic training. I think we are all in agreement, those
of us who have been part of master training, that this is the type of program that
goes beyond your simple giving you the tool and showing you how to use the tool.
There is a heavy evidence base that underlies the entire TeamSTEPPS program.
Slide: To Err is Human
As I turn to page 3 of our presentation one thing I want to point out is that you
are all familiar I’m sure with the IOM report that was published in 2000 by Cone,
Corrigan, and Donaldson. I think this is more background than anything else. To
Err is Human is something that is salient in all our minds I’m sure. And as you
know, this is the great impetus for the development of such a program. It is important
to note that the major finding of this report, if any, was that communication, or
miscommunication in many cases was the largest contributing factor to the occurrence
errors, near misses, and other incidents. Examples of this were breakdowns
in communication because of differing communication styles held by providers.
Everyone understands that we all speak in different schema or different knowledges
and have different
knowledge bases especially when we’re all trained from one circle or from one school
of thought. Another contributing factor to miscommunication was perceptions of unwelcome
communication when dissenting with group treatment consensus. The primary recommendation
of this report was to address these problems by designing and interdisciplinary
team training program to reduce the occurrence of potential breakdowns in communication.
Following this report I’m sure you all know by now that the DoD and other agencies
throughout the government formed what was called the QuIC or the Quality Interagency
Commissioner Taskforce, which acted fast to produce a standardized team training
program or the or best practices for such a program.
[interruption as someone joins late]
Alex: Good, welcome aboard. The end result of this feverish effort by multiple
government agencies was and is TeamSTEPPS. This was and is the standardized federal
program for medical team training
Slide: QIO Experience with Healthcare Partners
TeamSTEPPS as a program fits in as a toolkit for QIOs that have years of experience
supporting healthcare partners. You all, I’m sure are aware of this. QIOs are designed
and entrusted to support quality improvement through problem and process analysis
with tools like RCA and FMEA. They are also designed to conduct activities that
include the use of models for improvement of organizational culture, cultural assessment,
change management, collaborative and consultative facilitation, and the sharing
of tools and resources. I think we’re all in agreement in understanding our charge
which is that we are improving quality improvement through facilitation of quality
improvement practices at healthcare partners. I think we have a question so I’m
going to go ahead and try to manage that question. And no that question has disappeared,
okay. Having said that one of the things we want to talk about today with TeamSTEPPS
is that it is a toolkit for fostering organizational change and improving quality
through QIO facilitation and consultative services, if you will, which often entails
the sharing of tools and resources. Am I boring everyone or are we getting to the
point where if anyone has a question? I will take your silence as complicit agreement
that we should move on.
Slide: Multidisciplinary Teams
Having said that, at the heart of all quality improvement interventions that QIOs
are entrusted to carry out is the patient care team. A good amount of all these
quality improvement interventions is designed to build upon or improve the performance
of this team. Currently patient care teams are comprised of healthcare providers
of various disciplines and various levels of training. This multidisciplinary nature
of the team and its work often belies the ability of the team to coordinate and
communicate effectively. This is often because, we all know examples of this and
we have seen examples of this, physicians are not taught teamwork in medical school.
Nursing education lacks assertiveness in training. Executives are concerned about
the bottom line, and that’s really a generalization, but it is often something that
is thought of when we think about obstacles to effective team coordination, and
more importantly oftentimes the patient or the family is not put first and listened
to. Each one of our QI interventions, when we consider our QI interventions, are
really targeted at mitigating some of these impacts and more importantly making
sure that a team of healthcare workers with various levels of professionalism and
often with various different agendas come together and coordinate effectively and
have some equal teamwork competency or standing. As you all know these artifacts
of organizations and the multidisciplinary teams often have a direct impact on the
effectiveness of an organization and the overall reliability as an organization.
Slide: Reliability and Perfection – What our Collaborative Partners Tell Us
Given that the reliability and perfection as an organization and as a healthcare
system typically are the objective one thing we learn in dealing with collaborative
health partners is that there are a myriad of barriers to attaining the goals of
higher reliability and eliminating medical error. Too often the common obstacle
is finding support for QI interventions from physicians. I’m sure if I were to ask
you to raise your hand I’m sure many of you would raise your hand saying that they’ve
had situations where physicians just didn’t buy in to a specific intervention. I’m
going to go ahead and address a question. Yes these slides will be available to
you later on.
Cori: And actually what I can do right now is put up in the handout section
a PDF version of the current presentation so if people want to look at it or print
out and follow along right now they’ll be able to.
Alex: These slides will be available later on. Thank you very much Cori and
that was a good question. I also want to go ahead and say that one thing to keep
in mind is that this recording will also be available later on. Other examples of
challenges include trying to build leadership buy-in to drive a specific program
or rather leadership support to drive a specific program. I’m sure we’ve all run
into the encounter where leadership will not buy-in or will not fully support an
intervention that is being fostered or tackled within one specific unit within the
organization. This often undercuts every effort to succeed with that specific intervention.
Still achieving reliability and perfection is also met with resistance from clinical
staff because it often requires individual accountability or accountability across
all individuals within the healthcare system. So this too undercuts the ability
to reach that unattainable 100% reliability. To that end it is incumbent upon us
as master trainers of TeamSTEPPS and members of the TeamSTEPPS community to really
share the tenants of the program to foster this reliability and remove some of these
obstacles, some of these barriers to reliability. You may have all noticed now in
the bottom right hand corner that there is a message that the handout is now available
for download if you are interested.
Slide: TeamSTEPPS Teaches Teamwork
So what does TeamSTEPPS teach us, and again this is part of what you all have really
encountered as TeamSTEPPS master trainers and as members of the quality improvement
organization community, is that TeamSTEPPS really teaches us about teamwork as a
function of four basic skill with the most important crosscutting skill being communication
across teams. TeamSTEPPS provides communication tools and techniques such as the
SBAR communication or information exchange protocol. I’m sure you are all familiar
with situation background assessment and recommendation. It provides you with situation
monitoring tools such as the STEP assessment, which really hones in on the information
that feeds an SBAR. It also provides you with conflict resolution strategies such
as the DESC script. It provides you with other tools slike the briefing, which is
an information exchange strategy fostered for leadership. And it provides you with
advocacy and assertion tools such as the CUS tool which stands for Concerned, Uncomfortable,
and this is as Safety issue. It’s really more a stop the line mechanism as you all
know. Tenants such as these really are what underlie TeamSTEPPS and can be used
to foster improvement at our organizations when provided by the quality improvement
organization’s staff to support initiatives at organizations. Having said that it
is important to note that tools such as these
I’m sorry
okay it is important to
note that tools such as these have also been given a video vignette or a video scenario
in the healthcare setting to really contextualize these situations for practitioners.
To really help you portray the use of these tools and communication techniques for
practitioners. So one of the things to keep in minds is that TeamSTEPPS really teaches
healthcare providers how to use these tools and provides an example of how these
tools might be used in a specific scenario. One thing to keep in mind as we kind
of review TeamSTEPPS here is that this is a toolkit that can be used by quality
improvement organization staff to really push or tackle problems that are being
encountered by healthcare partners. The side benefit or the side-carrot for you
as healthcare quality improvement organization staff is to go ahead and consider
these
[interruption as someone draws on the slide, this function is now turned
off] The thing to keep in mind with this the side-carrot or the nugget for you all
is that this can be used to address many of the targets or many of the target areas
or outcomes that you will be measured by as far as the scopes of work, the 8th scope
of work as well as the 9th scope of work by CMS.
Slide: TeamSTEPPS 8SOW Applicability
One of the things that we need to think about is how does TeamSTEPPS apply under
the 8th scope of work. When we think about the 8th scope of work one thing that
does come to mind is that TeamSTEPPS can really be used as a toolkit to address
a host of metrics that will be used to gauge your performance as a quality improvement
organization. Consider for instance that TeamSTEPPS tools and strategies can be
used to address surgical care improvement, heart failure care, 30 day mortality,
prevention of pressure ulcers, which is a large metric not only in this case but
the 9th scope of work as well. It can also be used to address management of diabetes,
prevention of readmission. Various metrics by which you might be gauged you can
kind of tie TeamSTEPPS tools or strategies to help address a lot of these problem
areas. Each of these kind of represents an example of care where preventable errors
occur as a result of medical team miscommunication or poor coordination. [background
conversation] I’m going to go ahead and ask that if someone is on the phone and
talking that they mute the phone if possible so that we don’t hear background conversation.
Thank you. As far as the TeamSTEPPS in the 9th scope of work
Slide: TeamSTEPPS 9SOW Applicability
It is clear that it applies to various targets in the CMS 9th scope of work. Again
TeamSTEPPS tools and strategy like the advocacy and assertiveness tools like the
CUS can be used to address preventable errors that lead to MRSA or HAIs. I think
we know about the example of hand washing and physicians who may not, and I hate
to pick on physician we can pick on staff in general, who fail to wash hands and
end up getting unnoticed and passing infections despite the fact that someone on
staff did notice it and didn’t speak up. Another example of this is proper information
exchange through TeamSTEPPS tools for communication which can be used to address
patient complaints and ensure the patients are heard and considered throughout the
entire process. One of the things that you learned about was that TeamSTEPPS is
a culture change initiative and a huge part of the patient care team or multiteam
system, if you will, is the patient. The patient is at the tip of the spear, as
they like to say in the DoD, and they are the ones who to some degree really push
the patient care team. Also important is effective hand-off strategies for transitions
in care which can be taken from TeamSTEPPS to address care coordination concerns.
At this juncture what I’d like to do now is ask Julia if she could say a few words
as to how TeamSTEPPS really applies under the current and future state of work and
what are some of the thoughts that are being concerned as
Cori: Could we pause for just a second?
Alex: sure sure
Cori: We’ve been asked to briefly provide an explanation of what is meant
by the 8th and 9th scope of work. And then I’d like to ask that if you are not actually
speaking through your telephone line to please mute your phone we’re having a little
trouble with interference and its causing Alex to cut in and out.
Julia: This is Julia and perhaps I can be a good candidate to answer that
question as well as address what you asked me about the 8th and 9th scope of work
I’ll begin with. Is that alright Alex?
Alex: Go ahead Julia, that’s perfect.
Julia: Thank you. And I’ll also let our listeners know that we are experiencing
a little bit of background conversation that you think might be far enough away
from your phone, but its not. And also when we hear the clicking or typing of keys
on the keyboard it comes right through so please note that the line is quite sensitive
and we appreciate your diligence in being just as silent as you can at your site.
QIOs, the quality improvement organizations contracting to CMS, work on contracts
that are approximately 3 years of length. The 8th scope of work is the contract
period that the QIOs are just finishing this year. The 8th scope of work has been
from 2005-2008 and QIOs were directed by CMS contract to tackle many objectives
as a part of that process on behalf of medicare(sp?) beneficiaries. So those items
you saw on the previous slide were specific quality improvement projects and requirements
that the QIOs were directed to work with their hospitals in their states on. You
saw the heart failure ANMI and various other objectives, which, thank you the slide
is going back now.
Slide: TeamSTEPPS 8SOW Applicability
Those of you who are on the line who aren’t QIOs who aren’t calling from quality
organization representative realize that our remeasurement is really passed and
that we’re gearing up for the 9th scope of work. But indeed I’m certain of the efforts
that you put forth during the 8th scope of work are still winding down; are still
in progress at your site hospital. So there is opportunity to help your facility
know at least some of the tools in the toolkit, the TeamSTEPPS toolkit, that you
could help them with even apart from getting that hospital a major master training.
And then in the 9th scope of work, go to that next slide, as Alex was describing,
I’ll clarify for the listeners.
Slide: TeamSTEPPS 9SOW Applicability
We are about to enter a new contract period under CMS where we have a number of
new objectives. These are only a small portion of them, but they are those which
are most closely applicable to QIOs’ work with their hospitals and their states
and these are the specific clinical quality improvement objectives that are outlined
in that scope of work contract where we do see an applicability for the TeamSTEPPS
program. All of the quality improvement organizations will then be embarking, if
they’re not already it’ll be after August when the scope actually begins, they’ll
be embarking on the specific interactions with their hospitals around how to use
and how best to use this toolkit for the various objectives. And I believe closer
to the end of this call we might be more specific about that Alex. I think that’s
the goal: to talk about how it might be applied and specifically how it might be
applied to helping hospitals work with decreasing Methicillin-resistant Staph aureus
transmission.
Slide: How do you QIOs use TeamSTEPPS?
Alex:Yes, one of the things that I want to point out here today is that as
we move through this presentation one of the goals is to really talk about how certain
organizations are using TeamSTEPPS to support their partner organizations. Having
said that, keep in mind that this particular organization, or this particular presentation
is kind of geared towards members of the quality improvement organizations who have
been trained as master trainers. I am aware there are several individuals who are
on the phone with us who are part of the master training group who do provide support
to other organizations or may not provide support to organizations but may provide
support to units within their own organization. Some of this information is still
applicable to you, but again the goal is really to tie this together for the quality
improvement organizations. So I apologize if everything is not applicable to your
organization, or to your particular setting. Okay, so now we move on to page 10
of our presentation. One of the things we want to talk about is that a good number
of you at the quality improvement organizations are on the brink of becoming master
trainers and/or have become master trainers. For example I know Julia became a master
trainer just about a year ago whereas other members on here maybe have some folks
from Indiana or Kentucky who became master trainers this past January when they
attended the Creighton training. Others still might be master trainers through PSIC
and through other programs. None-the-less we kind of want to go ahead and address
the fact that we’re targeting this towards quality improvement organizations here
today. As master trainers I’m sure you walked away from your training and said “what
do we do now?”, “how should we be supporting our partner organizations?”, “Are there
other QIOs who are using TeamSTEPPS?”, “How are they using this TeamSTEPPS toolkit?”.
One of the questions that we get very often when we’re providing support to members
of various programs is “how should we be going about targeting our metrics or our
areas for performance improvement and performance measurement under the CMS scopes
of work by using TeamSTEPPS?” What I’m here to do today is discuss some of that
information, discuss how you would go about using TeamSTEPPS and the TeamSTEPPS
toolkit, and what the specific role for quality improvement organizations are in
meeting their contractual needs as well as giving you examples of what are being
done current to support some of these quality improvement interventions using TeamSTEPPS.
Slide: What Do We Do Now?
So, let’s go ahead and try to answer the question “What do you as a QIO do now?”
Well the easiest answer to this is to make sure that your partner organizations
know that you are TeamSTEPPS trained and certified to go ahead and provide TeamSTEPPS
training or support a TeamSTEPPS based initiative. The biggest thing that I think
happens in one anecdotal example of all this is that we have various organizations
who have been trained in TeamSTEPPS and don’t know there are QIOs out there that
are ready to support them with TeamSTEPPS based projects. So make sure your organizations
know that you can support them with TeamSTEPPS based projects. Also we want to go
ahead and make sure that you can help them, that they know that you can help them
with implementation. A big part of what is taught during the master training course
is to go ahead and identify how you would implement this particular process, how
you would implement this particular culture change initiative. QIOs in particular
are being trained how to facilitate or support organizations who are trying to implement
TeamSTEPPS. So you’re learning about action planning, you’re learning about development
and implementation planning. And Dr. Mel and I want to point out that we are not
ignoring your question, I do want to go ahead and answer that later on in this presentation
and this webinar. Okay? The other thing I want to point out is that you want to
go ahead and make sure that your group or partner organizations knows that you can
help them by coaching and offering continuous feedback as they see fit and as they
are willing to go ahead and seek out.
Slide: Supporting Organizations in TeamSTEPPS
So let’s talk about supporting organizations in TeamSTEPPS, or supporting organizations
who are trying to develop or implement a TeamSTEPPS based initiative. The biggest
thing that I think we want to hit home here is: find out if organizations are really
trying to initiate TeamSTEPPS based interventions. One of the things that we’ve
encountered is that many organizations have examples of TeamSTEPPS based initiatives
going on in their L&D units, their emergency departments, elsewhere and don’t know
that quality improvement organizations can provide support for this effort. I can
think of one organization in particular in Minnesota who did not know their quality
improvement organization could support them in the emergency department with the
implementation of SBAR. The other way to tackle this particular problem or to support
organizations with TeamSTEPPS is to really find out and be proactive when finding
out if your organizations are having problems with communication breakdowns. Are
they having problems with transitioning care or handoffs? Are they having problems
with nurse-physician relationships? Are there adverse events taking place? Are there
near misses? Any time an organization comes to you and says “We have a particular
breakdown or a particular organization.” And I understand that organizations may
not come to you directly or often but find out whether or not there are situations
that could be tackled by introducing a TeamSTEPPS based initiative. The beauty of
this and in particular thinking about TeamSTEPPS based initiative is that this is
the type of initiative that an organization can go ahead and take with them and
really they are the ones that control this and you support them through this process.
This gives them ownership of the specific intervention, which is not necessarily
the case with other types of interventions.
Slide: Supporting Organizations via Implementation Planning
Now let’s talk about support training in particular or action training in particular.
During your master training, if you attended master training, one of the things
that you were taught is how to plan for implementation. As a QIO it’s a little bit
trickier because you want to go ahead and support someone as they implement their
TeamSTEPPS based initiative, but you are not necessarily a member of that organization.
So what roles would you take on to really address or support them through this process?
Well we have examples of individuals who serve as a sounding board for implementation
to the change team. We also have examples of individuals who serve on the change
team within a specific organization supporting that organization. The key to any
of these roles is really to develop and understanding of what change teams goals
are and really to assist them with all aspects of the TeamSTEPPS initiative as you
see fit and as they want you to be a part of. Sometimes this might include being
part of their communication and marketing at their facility, whether it be supporting
them in developing leadership buy-in, supporting in building buy-in with other organizations,
supporting them with providing them examples of how TeamSTEPPS has succeeded or
changed situations at other organizations. As you learn and kind of grow as a master
trainer and develop as a master trainer I’m sure you’ll compile anecdotes, information,
data that might really help you build a case to leadership and other administrators.
You might also consider assisting them with developing the implementation plan that
includes evaluation. One of the things we discussed during master training is that
evaluation is really the toughest part of the entire initiative but you can show
your mettle, if you will, by helping these organizations really achieve a plan that
really includes the evaluation piece of this so they can go ahead and show their
successes.
Slide: Supporting Organizations via Coaching & Feedback
Implementation training however isn’t the only way you can support your partner
organizations. You can also support your partner organizations by providing coaching
and feedback as you see fit and as they so request. Keep in mind that oftentimes
coaching can entail providing behavioral modeling of the use of tools. It might
entail providing them an extra set of eyes to witness their simulation or be a part
of their simulations, to improve communications, or improve coordination amongst
teams. It might entail facilitating a follow up training of sorts. It might entail
engaging in role play exercises and being that resource for them. It might even
entail helping them engage in interactive learning and really being that sounding
board coach for them that really pushes them to improve and continue improving and
sustaining the behaviors that they are learning.
Slide: Supporting Organizations via Coaching & Feedback
In addition to coaching one of the things that you might want to think about is
providing feedback. When we think about feedback, and we typically think about it
in terms of one on one feedback and how teams can go ahead and use feedback to improve
their own performance. Well the same thing is true for the change team and for the
overall unit you might support with a TeamSTEPPS based initiative. Consider for
example conducting observations of TeamSTEPPS tools in use when requested. I can
think of an example of a QIO that actually lends out staff to conduct organizational
observations of teamwork behaviors at a specific facility in Michigan. This particular
QIO provides staff occasionally at the request of the group with the goal of literally
focusing on and observing the behaviors that are being used and that were learned
as part of their TeamSTEPPS training. Another example I can think of is providing
staff to lead debriefs with various staff and facilities as a real, serving as a
real mediator or someone who is an outside source providing constructive criticism
about teamwork behaviors and teamwork coordination during treatment. Oftentimes
this really provides the QIO with the opportunity to really serve as an impartial
person or an impartial judge of what’s going on and provide incisive support. Finally
another example that we can think of is compiling observation feedback from others
to share with the unit where TeamSTEPPS has been implemented. The best example of
this that I can think of is I know of one particular labor delivery unit where QIO
staff have been invited to receive all information or all reports about team performance
from all team members and they are asked to provide a conjoined report or a compiled
report on the effectiveness of the team that comes from an independent third party
and is made confidential and anonymous so no one is attributed with observational
feedback or bias or judgments of that kind within the team. Are there any questions
at this point? Anyone have any other questions? Anyone want to go ahead and post
a comment or a thread of thinking? Anyone? Okay.
Slide: Are there other QIOs using TeamSTEPPS?
So the question for you all and one of the things we’ve really been asked by several
QIO staff across the country is: “Are there other QIOs using TeamSTEPPS?” And the
answer to this as you can see is a resounding yes. We have three examples that we’d
like to point out in particular at this juncture with this presentation and these
will remain anonymous as you will see, but they are existing examples that you may
have learned about even through PSIC or other programs of that kind. [background
typing]
Slide: Example 1
Okay, so in the first example I want to provide you with a case where an individual
QIO staff member was approached about a TeamSTEPPS based initiative for medication
reconciliation. In particular this QIO staff was asked to help this group identify
a better strategy for reconciling all medications that a patient was taking before
treatment took place in an emergency department. The QIO staff actually suggested
to the team that they use something of a modified hand-off checklist for triage
personnel. And this checklist included questions that required listing of all possible
medications and moreso provided a protocol for treatment planning without medication
information in hand. So it really kind of set forth a category for treating a patient
who was in a particular level of trauma without indicating all the medications they
have taken or are taking at the time. Again this is something that was brought up
at the suggestion of the QIO staff and was shared with the group and is actually
in use today at the specific hospital. It is something that is still being worked
upon and is still being narrowed down because of the various issues with not providing
immediate treatment for high level traumas but it is something still that is being
honed and developed based on a TeamSTEPPS tool.
Slide: Example 2
In our second example I want to point to the case of a emergency department who
was having trouble with specific transitions in care and specifically with hand-offs
if you will, and the communication that was exchanged during these transitions in
care. Namely nightshift changes and/or overall hand-offs. It was an extremely pervasive
problem. The biggest part of the problem was that information was not full provided.
In particular 68% of the time ED staff forgot to provide an assessment of the situation
that was taking place with a specific patient. More than half the time, and I know
this might be a bit shocking, handoffs only really consisted of patient names, vitals,
medications orders, and the physician name for the physician who has been seeing
the particular patient.
Slide: Example 2 Cont’d
This is something that even to me as a layperson can sometimes is still kind of
shocking, that this is the only information being passed along, but I can see that
scenario happening. Having said that, QIO staff were approached by emergency department
leadership, and in this case it was two physicians in specific, who wanted to find
out about the SBAR communication tool and in particular they formed a change team
which was assembled with QIO staff actually being a part of it via teleconference
and helping shape using the SBAR tool. Subsequently SBAR training was conducted
by QIO staff via video conference. So it was not a high expense endeavor for the
QIO and yet it had great yield for the emergency department. Finally there were
role play refreshers that were held by facility staff every three months which were
facilitated virtually by QIO staff.
Slide: Example 3
Does anyone have any questions at this point? Okay. The third example I think is
the most interesting one and Julia and I were discussing this one earlier this week
and we were talking about how this might be the most innovative one that has come
across to this point. And it deals specifically with the treatment of patients and
improving patient satisfaction. QIO staff actually heard about this from hospital
leaders because of poor patient satisfaction with one target population in particular.
The target population we’re talking about here in particular is sickle cell disease
patients. As many of you know this particular population requires a lot of pain
management for their condition and the pain management often entails providing a
heavy degree of opiates. And as we all know managing opiates is a tricky situation,
namely because it is often risky and there is a big risk of assuming that these
patients are either developing an addiction or have an addiction at the moment to
these opiates. This particular hospital was told or was provided with the possibility
of using an advocacy tool to foster the proper treatment of patients or to foster
a culture change in the way patients were treated. Let me give you some background
here in particular with patients who came in for pain medication for this particular
disease. What happened was the hospital first tried to implement a patient monitor.
Some one who could really monitor them and really stick with them throughout the
patient medication process to ensure that the patient was not exhibiting addictive
behaviors and moreso the patient was not being mistreated by staff. After about
a year of implementation of this particular program what became very apparent was
although patient monitors were support staff and/or part of the team they were not
very well respected because of their judgment. And more importantly this had an
impact on the patients because the patients did not feel as though they were being
heard or treated fairly because they were aware they were being suspected of addiction.
As a follow up to this what this particular hospital leadership decided to do was
go ahead and arm
Slide: Example 3 Cont’d
the patient monitors with an advocacy tool for the patient and in particular they
armed them with a CUS word like tool with a card and the staff were taught to respect
the monitors and to really respect the CUS mechanism, if you will. Today this hospital
is actually improved as far as patient satisfaction for this particular population
and they’ve also had the side effect of improved staff satisfaction because of the
way that particular staff is treated. Of course this comes at the suggestion of
a QIO staff member who was trained as a TeamSTEPPS master trainer. They are even
thinking about evolving this particular program by enabling family members to use
this CUS tool during admission or following pain medication management and they
are also thinking about going ahead and training the treatment staff to really include
and/or adhere to the patient’s wishes and the family’s wishes as part of the care
team. So this is, as you can see, is an example of an innovative program that has
kind of flourished and really took just one piece of the TeamSTEPPS toolkit and
used it to tackle a specific problem all because a QIO staff member had the idea
in the back of their heads.
Slide: Do you have any examples?
Julia would you like to at this point talk about how you’ve seen some of these examples
and how you are thinking about the TeamSTEPPS toolkit to address various problems
or communication breakdowns at other partner organizations?
Julia: Sure, thanks Alex. I’d just like to interject at this point is many
of you QIOs or hospital teams on the call may be looking at these three examples
and thinking “Yes this is quality improvement, this is using tools and strategies
to assess the problem and to find a mechanism or a particular tool to tackle the
improvement. Creating a checklist, using SBAR communication which many of you knew
about before, learning about TeamSTEPPS, or an advocacy kind of a tool.” The beautiful
thing about this TeamSTEPPS product and program is that as you know from attending
master training is it takes you beyond knowing about the tools and about a checklist
format or about the SBAR communication, and it gives you and the facility actual
videos, role plays, mechanisms to know not just about the tool but how to successfully
implement it. How to approach a team through implementation so they might be successful.
How to help them get past that improvement to 90% but get closer to 100% reliability
in a perfect application of a process. And that’s really the exciting thing about
this entire toolkit and program. Think to yourselves that what really is at the
beginning of those improvements and initiatives is to create that shared mental
model and in order to get large numbers of that patient care team at the site to
actually adopt that changed shared mental model.
Slide: Example 3 Cont’d
This kind of a program, the way it can be taught and profused throughout all of
the staff members is key. I like especially the last bullet on Alex’s slide, that
staff was taught to respect monitors and the CUS mechanisms. What these TeamSTEPPS
initiatives are selected by your organization that you’re helping. One of the main
coaching tools to apply is to help them understand how to disseminate, really, that
shared mental model and enjoin that respect and that participation by all the members
of the care team. And in particular I think it is that some of the video tools in
its contents that will help a healthcare team really see themselves and realize
where there is [inaudible] and unwelcome communications and how it will be valuable
to create an initiative that supports all of the organizational participants to
get on board and to share that mental model and to achieve the goals
Alex: Thank you very much Julia, those were excellent points. I want to go
ahead, and I see we have someone with their hand raised and I apologize [Participant
1] if I mess up your last name. [P1] go ahead.
[P1]: Oh thanks, this is a really good presentation, we really appreciate it. There
are two of us here at [inaudible] that have been trained a couple of weeks and so
what we’re doing next week is we are practicing in our own QIS staff, quality improvement
services staff, which numbers about, uh, we’ll have 8 or 9 to not only practice
but also there is a number fit that would do well within our own department because
we want the credibility saying “Yes we’ve used it, yes we’ve implemented, yes we’ve
fought thought he migraines or the difficulties of some people not being particularly
interested. So I just wanted to put that out there that as an intermediate step
before rushing out to a hospital we want to get a little experience of actual operationalizing
it internally. I’m done.
Slide: Do you have any examples?
Alex: Okay, do we have other comments or questions? Okay, I see no other hands
raised. Okay. So I’m going to go ahead and ask you now as a group to think about
what other examples you might have encountered when providing support to your partner
organizations. And what I’d like for you to
[classical music begins]
okay
am
I the only one that hears that or does everyone hear that music?
Cori: I think someone just put us on hold.
Julia: at least it doesn’t take away from our ability to hear you Alex.
Alex: Fair enough. Having said that, I want you to go ahead and consider if
you have any examples of how you or your organization has supported hospitals using
TeamSTEPPS, because I do know that a good group, a good number of you, have known
about TeamSTEPPS for quite some time and have used TeamSTEPPS for quite some time.
As you think about this I want you to think about what your primary support function
has been. Think about what support functions you have undertaken as part of this,
and more importantly I want you to think about how you have been most helpful using
TeamSTEPPS to these particular hospitals.
Slide: Do you have any questions?
And as you think about these things what we’re going to ask you to do is if you’re
willing and interested to provide this information anonymously we’d like for you
to go ahead and submit this to us as we prepare our webinars of the future, which
will tackle some of these problems also. Having said that, I do want to go ahead
and point out that we have reached the end of the initial part of this presentation,
the first part of this presentation. And so I’m going to go ahead and begin some
polling. Having said that though, I do want to open the floor to any questions.
Please don’t hesitate to ask questions. If you don’t feel comfortable asking questions
don’t hesitate to contact us directly. You’ll find contact information for all of
us there, except for Julia, and I can provide that contact information cordially
immediately following this webinar. You can reach us via e-mail or
Julia: Excuse me, this is Julia, can you hear me?
Alex: Yeah I can hear you. Go ahead Julia.
Slide: Do you have any examples?
Julia: O kay, I’d also like to let you know from the listening in that for
some reason even in the midst of your sentences when someone is keying in or keying
out of your calls then we lose chunks of your sentence. So for some it may be difficult
to understand the requests you have given them to share examples and indeed as I’m
speaking the same thing may be happening to my end, I don’t know. And let me know
also if this is a time you’d like to leave open for a little bit more for how we’re
thinking of applying TeamSTEPPS at hospitals with MRSA.
Alex: Oh, yeah, absolutely. Julia please go ahead and jump into that. I apologize.
Go right ahead, please do just jump into that.
Julia: Okay, sure. On this end I’m thinking about 5 to 10 minutes of suggestions
as QIOs are beginning to think how they might roll out TeamSTEPPS to your organizations.
Alex has given us a great number of examples about how we can be good shop owners.
And that’s what I thought first about this TeamSTEPPS toolkit. Its like an entire
store of tools, coaching mechanisms, feedback exercises, to help hospitals get over
that barrier between improvement and excellence. So, the first thing we want to
be as QIO master trainers is just good shop owners, that we know exactly everything
that’s in the store and we keep ourselves [inaudible] as we listen to the needs
of our hospitals [beep] and as Alex described earlier that we be thinking when they’re
communicating a difficulty or problem, we be able to pull up some tools from our
store, the TeamSTEPPS toolkit that will help them over the hump and we coach them
through it. So that’s one way of thinking about applying TeamSTEPPS to your hospitals,
nursing homes, and other organizations that you’ll be helping with following. Then
more specifically we know that the 9th scope of work directs us to use the TeamSTEPPS
toolkit in location safety initiatives for [inaudible] MRSA in the hospital, and
as many of you know there are initiatives that can be employed to help tackle that
particular problem. Perhaps it is the IHI initiative that gives a good concise listing
of what some of those improvement strategies might be. The perfect management of
universal precautions and hand hygiene for all patients in hospitals is one. A second
aspect of that initiative is to employ contact precautions for patients who are
infected with or colonized with Methicillin-resistant Staph aureus and a third area
to consider is directive or targeted surveillance, culturing of staff and patients
in the hospital either on a widespread basis or on a directed basis looking for
those most at risk or most likely to be colonized. And initiatives for a different
and more concentrated approach to environmental cleaning of the areas of the hospital,
the patient care areas of the hospital. So as you arrange with your provider organization
to have that first meeting, that first sort of a TeamSTEPPS training. I believe
our contract at this time suggests that we be directed to train one physician and
one nurse at minimum at our client organizations, and to help them with application
of this TeamSTEPPS toolkit to managing their MRSA initiative. I think that we in
California will be considering that first intervention with those selected hospitals
to include not only the physician and nurse, and in each of your organization you
might decide who would be that population you want to reach but also perhaps the
first staff of candidates that would be most accessible to do the initial orientation
of TeamSTEPPS with would be the QI director who often has an interesting background,
and the quality physician chairman or a physician champion in that organization
who helps that hospital with its quality improvement projects. If that [beep] plans
for example, and this is only some opening ideas
QIOs will all find their own way
to roll this out to their hospitals, but [inaudible] MRSA effort we’re thinking
our initial meeting at the hospitals might be a day and a half or two days and that
the first half of the first day we would invite not only that physician and nurse,
the QI director and physician quality champion, but in addition perhaps the CON
and the chief of staff or other administrative officials in the organization so
that at least for the first part of the first day you can begin to cheer with them
how the TeamSTEPPS program and package will help them with that shared mental model
throughout the organization and they can begin thinking what would be the best areas
to apply this toolkit, to apply this program in our organizations. Sort of inspiring
them, as it were, to understand the value of creating that shared mental model and
opening the idea that a facility wide assessment about their current culture and
readiness to undergo a change initiative would be part of the program. So we think
that involving senior officials at the hospital in addition to that required component
of a nurse and a physician will be important to the first step of our introduction
to the hospitals of the TeamSTEPPS project. And then what we intend to do is design
our program for the hospitals to get them thinking after an initial introduction
of the wonderful components and value of the whole toolkit. Then they introduce
their thinking we want you to be evaluating as you look at these tools in the program,
where is an area in your organization where you think this might be most helpful,
perhaps a quality improvement project that is waning, not reaching the excellence
that you are hoping to reach so that in the course of the one and a half or two
days that we spend with them that we can begin to help them right there with that
particular initiative. And then within that first day we’ll also be introducing
to the hospitals those various approaches that I mentioned before for MRSA management,
control and management in the hospital and take along with them, help them to think
which of those components of a typical MRSA reduction campaign might they like to
start with. As a coach you’re helping your team look at the options, but then you
let them help design the game plan, and that’s part of the task we intend to take
when working with our hospitals on this. In addition we would probably be presenting
to our hospitals a sort of a change package, a specific toolkit if it were, that
is available by gathering resources from other sites such as the IHI.org site where
there are some wonderful articles and strategies very specific to MRSA reduction
in hospitals so that there’s a good evidence base. Articles, tools and interventions
that we can add to this more general and effective toolkit that TeamSTEPPS offers
us. So we would expect to be sharing some specific change package time and strategies
with those hospitals we’ve targeted to introduce this product to work on MRSA with.
So much of the train the trainer that we do with our hospitals will also be occurring
during that two day interface, but of course ongoing. We’ll be training them to
be the store owners themselves and understand all that is in this toolkit and how
best to apply the various aspects of it in order to achieve the results they need
to achieve in their specific unit or on an organization-wide initiative. I’m think
of, sort of the, small type of change approach that many of us learned and applied
as we have helped our hospitals work with quality improvement initiatives. The same
thing can be thought of with this TeamSTEPPS toolkit, whether the initial, sort
of a small sense of change, initial entry for this specific toolkit is on a specific
unit, like for instance the surgical care unit talking about briefing and debriefing,
specific care units, what, labor and delivery. This is done, going unit specific
can be one way to employ the TeamSTEPPS product in a small sense of change fashion,
making it unit specific or it can be intervention specific. Perhaps if we’re rolling
out an idea of MRSA control and prevention and we want to think about all four of
those different initiatives we would consider using the TeamSTEPPS tools to tackle
just one of those initiatives first and maybe to just tackle that on one nursing
unit in order to roll it out carefully enough to apply the small sense of change
theories to be able to then tackle any barriers that are discovered, perfect that
before its rolled out hospital wide. So I really see the enormous value in this
package. I would have a little trouble deciding which term to apply to this model
of program, because it is more than a package, it is more than a toolkit, it is
an entire program, its an enormous resource for all of us, and many of the consultative
efforts that we undertake with our hospitals.
Poll 1
So we really use it as much of an entire program as it is a package or a toolkit.
You see that we have an opportunity on kind of a specific basis thinking about how
to help our hospitals with MRSA which we all know we need to do as part of our contractual
arrangement, but the same time having our hospitals understand the widespread applications
and helping hospitals other than those we’re helping with MRSA, to employ this with
their other campaign. So we intend to help hospitals identify to themselves what
other area they’d like to try this in and I enjoyed James’s comment from (can’t
hear). We have decided the very same thing at Lumetra, to sort of roll it out internally
and discovered applications in the office setting as well as in interaction with
providers that other arms of our QIO perform over the phone.
Slide: Do you have any examples?
The provider query, and the follow-up with beneficiary complaints and indeed I’ll
be training, holding several training sessions in the middle of June at Lumetra
for our own internal staff to various degrees. Those who will be actually be taking
it out on the road to providers, QI (can’t make out word) like myself will be receiving
a full two day after training at our QIO, but then I’m also putting on half day
sessions for others of our organization to help them learn the value of this application
as to how they might use it in their own setting. So I appreciate your commenting
on that and we’re going to do the same at Lumetra in California.
Alex: Julia, thank you. We do have a question that came up or was raised,
which is whether or not the CMS 9th scope of work requires that a QIO train a physician
and a nurse TeamSTEPPS.
Julia: Yes I have an answer to that. I have to give a caveat first, that every
QIO knows that contract modification comes along throughout this scope of work,
but that was what we saw in the initial RSE for the 9th scope of work contract.
The verbiage was that the QIO would train a physician and a nurse. Now it may be
that subsequent iterations of the contract clause have altered that somewhat. It
may be that we will get specific toolkits and specific information from CMS or details
about how they want us to work with their hospitals on MRSA. But the physician and
the nurse language was taken from the initial request that we all responded to at
the beginning of our contract.
Alex: At this point we’re going to soldier on even though we have classical
music in the background. You may have noticed as Julia pointed out my voice was
cutting in and out during the various folks coming and going on the phone line.
Having said that, if we turn back to slide 23.
Slide: Do you have any questions?
One of the things that we wanted to give you as kind of a homework assignment: if
you are interested is to provide us with examples of how you and your QIO staff
have really supported other organizations with TeamSTEPPS or the use of TeamSTEPPS
tools and strategies.
Poll 1
If you want to go ahead and forward that information to anyone please do so to me.
You’ll see that I’m Alex Alonso, my e-mail is right here
Slide: Do you have any questions?
you can see it right there. Okay? I’m sorry did somebody want to say something?...
Okay.
Poll 1
You’ll also note that I posted a poll for you to go ahead and respond to and you
can go ahead and answer that poll at any point throughout this process. The poll
is namely asking
[comment about inability to hear due to hold music. hold music continues. There
is a conversation about ability to disconnect from the person with music. hold music
continues. Moderators decide to try to continue despite the music.]
Julia: This is Julia, Alex.
Alex: Yes.
Julia: Can you hear me?
Alex: Yeah, I can hear you Julia.
Julia: I’m able to see some of the Q&A and indeed I could clarify that. I
never intended to suggest that you were to train a nurse and a physician with all
of our providers, just a select number who are in the NHSN database as reporting
on MRSA, the initial RS communication that group from which you would choose from
hospitals to work on this with and that for those we would train a physician and
nurse. I did not mean to imply that it was all of our provider hospitals.
Slide: Upcoming Schedule
Alex: Oh, okay. Thank you for that clarification Julia. Okay, at this point
what I’m going to go ahead and do is switch back to our content. And thank you all
who have voted on our poll or responded to our poll. One of the things that I do
want to point out, and I apologize that I’m cutting in and out because of this,
is that we have an upcoming schedule of webinars. That includes a webinar that will
focus on part of what we’ve been talking about here today, which is guiding implementation
for healthcare organizations. And that is scheduled for Jun 18th at from noon to
1:30 eastern standard time. Again if you’d like to participate in any of these webinars
it’d be good for you to contact Cori White at cwhite@air.org.
Slide: Webinars
She has all the information and is the caretaker for our webinar system. We also
have another one scheduled for July 30th from noon to 1:30 eastern standard time.
Slide: Seeking More InformationThis
Topics include determining readiness and developing a strategy to build administrative
buy-in. I’ll go ahead and move forward just a bit and let you know that these webinar
reportings will be available via e-mail and via the DoD patient safety center website
shortly. In addition I’d like to now turn this over if possible to Dr. David Baker
who’s our lead project director to discuss some of the resources that are available
to you as TeamSTEPPS master trainers starting with the new TeamSTEPPS website, which
is live. Go ahead David.
David Baker: Yeah, hi, I don’t know if anyone can hear me, this is David Baker,
AIR, and I’d like to let everyone know that the website for the national implementation
[inaudible] that’s live this week. Which means that you can log on there and get
more information [inaudible] hospital website for additional information. In addition
there is a tool on there that folks can use to determine whether or not they are
ready to undertake the challenge. It may be useful for you as well. And finally
we’ll have updates and new tools coming in the future. So one of the things that
might be particularly relevant to the QIOs that you work with your hospital partner
that are creating an under 15 slide leadership brief for hospitals to kind of market
the concepts to people very succinctly about what TeamSTEPPS is, what are the benefits,
and what are the costs that are associated with it. So that will be coming here
within the next 30 to 45 days. So I would recommend that you check the website regularly.
One thing that we may come back to you and ask in the future as we try to evolve
this whole process as QIOs that view themselves ready to deliver and assist hospital
systems that they’re affiliated with, whether or not they’d be interested in being
listed on that site with contact information and the like, because people may go
there to find out more information about the program and this would be another avenue
for your own personal [inaudible]. So that’s a couple of additional things that
are going on, and I’ll turn it back to you Alex.
[the hold music ends]
Alex: Thank you David. I do want to request again for those still in attendance,
please do not put us on hold anymore, as the hold music has prevented us from pursuing
this, or continuing the webinar. I request that if you do need to put us on hold
or need to mute the phone that you go ahead and do that, but please do not put us
on hold because the music is preventing us from actually having a decent recording
of the webinar. Thank you. Okay, I want to thank David for having gone ahead and
provided information about the website which is now available. That website again
is www.ahrq.gov/teamstepps
Slide: THANK YOU!
It’s live. Anything you want to find out about the national implementation project
or resources surrounding TeamSTEPPS can be found on this website. Further resources
include the TeamSTEPPS guide to action and you can also find information on the
DoD patient safety center website regarding TeamSTEPPS. At this point we are now
finished with our first ever TeamSTEPPS webinar. I want to thank you all for bearing
with the technical difficulties that we’ve encountered. I want to thank you all
for participating and I want to apologize for any nuisances that might have popped
up preventing this from being an effective learning experience. But I promise you
we will get all those wrinkles ironed out soon. Thank you very much and I hope you
all have a good day.
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