National Implementation of TeamSTEPPS Program Webinar 20:
SHARING THE SUCCESSES OF TEAMSTEPPS - PART 2

Moderator: Corinne White
May 25, 2011
12:00 p.m EDT

Operator: Ladies and gentlemen thank you for standing by and welcome to the Sharing the Success of TeamSTEPPS - Part 2.

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. Should you require operator assistance, please press star 0.

As a reminder, this conference is being recorded, Wednesday, May 25, 2011. I would now like to turn the conference over to Corinne White. Please go ahead.

Corinne White: Hello. Good afternoon and good morning to everyone who’s joined us today. This is the 20th Webinar in the TeamSTEPPS National Implementation Program Webinar series.

Our theme today is “Sharing the Successes of TeamSTEPPS - Part 2”. Those of you who have been attending Webinars for a while may recall that Part 1 was our 13th Webinar.

Our goal today is to share where we are and what folks have accomplished as a result of the National Implementation Program. This is not going to be a formal report on the state of the National Implementation Program.

Instead, we decided to give the TeamSTEPPS community an opportunity to tell us about your experience with TeamSTEPPS and how your implementations are going.

Today we have three groups scheduled who volunteered to share their stories with us and we will hear from each of them as we go.

I would like to start with a quick reminder for those of you on the phone. We ask that you consider others while participating. If you're not speaking, please mute your phone.

Please don't put us on hold if you have hold music or advertisements. Obviously, we can't be better than our worst connection.

At this time, Alexa would you please give us the information on how to use Live Meeting?

Alexa Doerr: Yes. Okay, well while many participants are joining us today through Live Meeting, some participants are only using the phone.

We'll tell you how to ask questions using the phone in just a minute, but I want to go through Live Meeting software in just a minute first.

For those of you who are joining us on Live Meeting, you should see right now the TeamSTEPPS slides and we're on the reminder side that Corinne just discussed.

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Operator: All right. If you'd like to register for a question, please press the 1 followed by the 4 on your telephone. You will hear a three-toned prompt to acknowledge that request.

Should you wish to withdraw your registration, simply press the 1 followed by a 3. We would ask that you please lift your handset before entering your request.

Corinne White: Great, thank you. So let me get to the agenda. This Webinar will follow the same format as we had in the past with some brief introductions to who we are and the National Implementation Project.

Then we'll hear success stories from three different groups and then we will have a brief Q and A after each presentation. Then we will have room for general questions at the end. We'll also give you some contact information at the end as well.

So the American Institutes for Research, we are the prime contractor for the National Implementation of TeamSTEPPS Project. We are not for profit, Nonpartisan, DC-based research organization.

We have 31 offices in the US and worldwide. We focus on health research, education research and workforce research. Our staff includes health services researchers, nurses and physicians and social and behavioral scientists. I would fall in that last category.

Our organization's mission is to better society through our research. A little bit about the National Implementation Program: The National Implementation of TeamSTEPPS Project, or rather TeamSTEPPS, was designed by the Agency for Healthcare Research and Quality and the Department of Defense to create a national infrastructure for the support of the adoption of TeamSTEPPS through programs like Quality Improvement Organization and the Patient Safety Improvement Corps.

Our goal is to make training available to early adopters and spread TeamSTEPPS, all while creating 2,400 new master trainers. To do this we are supported by several organizations as part of our team for the overall program.

They include our team resource centers. Minnesota, Carilion, Duke and Creighton are the original four and then in 2009 we added the University of Washington. AIR is headquartered in DC to lead the overall program.

Our sponsors are The Department of Heath and Human Services, specifically the Agency for Healthcare Research and Quality, and the Department of Defense, more specifically TRICARE Management Activity.

The AIR Project Team consists of Deborah Milne, the Project Director, Nancy Matheson, who is the Research Task Lead, Alexa Doerr, who supports the entire project and me, Corinne White. I support Webinars.

We do act as an interchangeable team. So if you need to get in touch with us, you can get in touch with any one of us. If you need to get a hold of us, we've provided contact information in this slide. You can contact any of us by email or telephone.

At this point, I would like to introduce Mei Kong and Abdul Mondul from the New York City and Hospitals Corporation. Mei Kong is the Senior Director of Corporate Patient Safety in New York City Health and Hospitals Corporation. She's also an Adjunct Professor at Long Island University and New York College of Health Professions.

Doctor Abdul Mondul is the Associate Chair of The Department of Medicine, Patient Safety Officer, Chief of Palliative Care Services and Associate Director of GME at Lincoln Medical and Mental Health Center.

Thank you both for joining us today. The floor is yours.

Mei Kong: Thank you. Today we're going to talk about the pursuit of patient safety through TeamSTEPPS implementation. Just to give you a background on who we are, New York City Health and Hospital Corporation is the largest municipal healthcare system in the nation.

We have 11 acute care facilities, four long-term care facilities, six diagnostic and treatment centers, more than 80 community health centers, a managed care organization, a certified home health agency.

The Corporation has over 38,000 employees, including contracted physicians. Our President, Alan Aviles, gave us a lofty goal on pursuing this - to be the safest healthcare system in the nation.

How is that possible? Well we begin with our people. TeamSTEPPS - teamwork and communication are the key components to patient safety. TeamSTEPPS was a great discovery, since our most important asset is our people and they can make the most impact in patient safety.

Abdul Mondul: Effective teamwork and communication, we feel, are very critical in delivering highly reliable and safe healthcare. They're also very important in improving the culture of safety in an organization or a corporation.

This slide we actually got from a model from Aviation Safety and it shows the progression of cultural safety in organizations. It's very important for organizations to reflect at what level we are.

These slides show the different levels. It goes from pathological, you know, who cares as long as we are not caught. This is the typical I stop at the red light, but if nobody's watching me, let me run the red light.

It goes up to a generative of cultural - organizational culture of safety. Safety is how we do business around here when we're constantly vigilant.

Unfortunately, I think at this point of time most of organizations are not really at this level of generative. A lot of organizations are at the reactive level, you know, we do a lot when something happens.

Some other organizations are at calculative level or proactive level in which we anticipate and prevent problems before they occur.

We feel it's very helpful to self-reflect to help us progress in these road to become one of the safest healthcare systems in the country.

Mei Kong: Our journey to TeamSTEPPS began with ten corporate leaders attending a master training session held by Carilion Clinic in Roanoke, Virginia.

In order for us to move forward, we had to train a group of master trainers. So the most effective and efficient way was to invite Doctors David Baker and Karyn Baum from AIR to New York City.

We had our first master training session at Lincoln Hospital where Doctor Mondul coordinated, and inspired the clinical and administrative leaders to attend, with great success.

Abdul Mondul: We kept on this model of training master trainers throughout the Corporation and we held it in our different facilities, both for the in-patient settings and the ambulatory care setting.

This is for us to build up a good number of master trainers to help us to spread the TeamSTEPPS programs and the word.

It's very important to make the case for our staff, both for our leaders and for our front line staff. We all know that communication failures have been addressed as the root cause of more than 70% of sentinel events that are reported.

We also have in our system and evolving approach to analyzing medical errors. At this point of time we actually have an increased focus on, Number 1, voluntary reporting and also, addressing errors from the system point of view - addressing system failures. All of this involves learning from front line staff and a need for transparency.

All of this involves our staff having effective ways of communication - communicating with us, of flattening hierarchies and empowering them to do so.

It's important also to consider the emergency of contingency teams. This is happen in all healthcare systems. In our systems we have rapid response teams. We have hypothermia teams for patients on cardiac arrest, stroke teams and for our facility we have recently established a behavioral crisis team.

So it's very important to get all those disciplines working together and being all in the same mental model.

There have been also changes in the working hours. We have a large number of residents and interns in our facilities and one of the important components of safety is safe handoffs, making them effective, making them relevant.

It’s a lot of work, and it's very important to focus on these areas. All of us know that there are regulatory standards that focus on communication. Things like critical values, you know, Department of Health, CMS focusing on ways of closing the loop in communication between multiple providers, referral processes, etcetera.

Lastly, in our physical situation, at this point of time in the physical environment, it's very important for all of us to work together. We need to be efficient, and we need to be productive and for this to occur, it's very important to work in effective teams.

Mei Kong: Building a solid foundation is key to successful implementation and sustainment. If you look at these building blocks, leadership support is critical for us to move forward.

Identification of champions and master trainers, understanding and buy in, education of leaders and staff, implementation and empowerment, and the last piece of course is sustainment, measurement of impact and celebrating success.

So the uphill climb for us is, you know, I'm sure similar to what a lot of folks out there are dealing with the nay sayers and “no no's” since some individuals do not believe they need to learn basic communication and teamwork skills.

So our challenge was to de-mystify that communication and teamwork is elementary and to share some of the brutal facts about patient errors related to poor teamwork and communication.

In addition, we wanted to provide the clinicians with a sense of purpose when they come to a TeamSTEPPS class by customizing the curriculum to meet their needs and provide relevance in their clinical focus.

We all are strapped with time and resource in terms of limitations and also deciding who should be the master trainers; and training, implementation, evaluation, sustainment and achievement are the other pieces that we'll talk about in a little bit.

Abdul Mondul: The reality. Yes, as we progress in our implementation process, we learn multiple aspects that have helped us expand the program hospital wide as it comes to Lincoln Hospital and in expanding it in all of our facilities across the Corporation.

One of the pieces is not all master trainers can teach and inspire. The quality of the training that is provided has a huge impact, a great impact, on the effectiveness of the implementation of the programs and sustainability.

We have also decided to master train some of our staff members, not to become trainers, but actually to improve gaps that we have identified in their communication and leadership skills.

Buy in takes time and as Mei said, it's much easier to get the buy in if we make it relevant. Training is the easy part. The challenge is making TeamSTEPPS and our task part of our daily activities.

For us to facilitate implementation and sustainability of our programs, it has been very important, Number 1, to identify and support those champions on those particular areas that we're implementing those programs.

The other component is developing measures so we can know at what level we are and we need to make some changes during our processes. It's very important also to recognize the efforts of both the front line staff, or these interdisciplinary teams and the champions for these programs.

Mei Kong: So the visibility is really critical in implementation of TeamSTEPPS because it is important to establish targets and goals. All of our facilities have a shared mental model.

It also helps engage the leaders to move forward and keep the fire going for the achievers. So HHC decided that our strategic quality and patient priority for 2011 included an increase of overall engagement of TeamSTEPPS into just culture by an additional 20% in fiscal year 2011.

So it's important and obviously it's not a matter of number of staff trained, but the quality in developing both relevant programs and a measurement of success.

As once we roll out these programs and we have implemented them, it's also very important to sit down with those teams and re-evaluate the effectiveness and re-evaluate the sustainability of those programs.

Education once is really not sufficient. In some areas we have gone back multiple times to be able to achieve our goals. In some other areas we have actually re-directed the emphasis on the specific tasks.

I can give you an example in our Telemetry Unit, initially in our assessment we felt we needed to work on escalation and conflict resolution and we focused and tailored the program initially on those tasks.

Once we achieved our goals, we later went back and focus on leadership skills. This has been very important for us.

Another component is to align TeamSTEPPS with other programs that are happening in your organization. For us, across the corporation, we've been focusing in different programs.

I'm going to mention four very important programs for our corporation at this point and time. One of them is addressing disruptive behavior. The other one is just culture which is, you know, balancing no blame in a just and fair culture.

Then there is the lean process that we call breakthrough in our organization. So it's important to make the links and to use the language of TeamSTEPPS when we're talking about just culture.

Integrating components of just culture into the lean process as teams work together improves and empowers our staff to address disruptive behavior.

The other component is with supporting early adopters. We can use these early adopters to cross train across facilities, across departments and across levels of care within the corporation to try to encourage and bring up to par organizations or areas that have been lagging a little back in implementation of the program.

Mei Kong: Just to share with you some of our successes since 2008, when we started TeamSTEPPS journey – Over 600 TeamSTEPPS master trainers are trained at our corporation and over 7,000 train on TeamSTEPPS modules.

Some of the specific unit and departmental successes measures, for example, labor and delivery. One of our networks, North Bronx Healthcare Network, had decreased rates of shoulder dystocia by utilizing the IHI model of oxytocin bundle.

With most disciplinary TeamSTEPPS approaches during simulation, they were able to decrease shoulder dystocia from 4% to 1.4%, Erb's Palsy from 1% to /3%. Also, adverse patient outcomes were decreased over 50% over a one and a half year period. So it's really significant when TeamSTEPPS work.

Abdul Mondul: In my hospital, Lincoln Hospital, one of areas we implemented TeamSTEPPS was our surgical area. We trained our surgical staff and during that time we worked closely on the implementation of the surgical safety checklist.

It was very successful. We measured our success by the patient safety culture survey. If we look at our outcomes, the feedback on communication about error improved from 72% to 82%, positive responses.

Handoffs and transitions in this area improved from 56 to 69%. Teamwork and communication as perceived by staff improved from 67% to 79% and overall reception of safety improved from 72% to 86%.

We have also sustained great outcomes in our surgical care improvement project measures. Our compliance with the process of going through the three steps of surgical safety checklists is 100%.

In our Psychiatry Department we have trained our multidisciplinary team of behavioral crisis intervention, which includes our nursing supervisors in the different shift hospital police and our psychiatry residents and attendings.

In our Emergency Department, we focus in our Pediatrics Department and their relationship with the Pediatrics In-Patient Unit. We work in the throughput from the Emergency Department for patients that are coming to our Pediatric Intensive Care Unit.

We have sustained a timing of less than one hour. It's actually 40 minutes at this point of time between the decision to admit to the Pediatric Intensive Care Unit and the patient being critically in our PICU.

We've worked in the Department of Medicine in multiple projects. I'm going to mention a couple of those. While we worked with our medical health staff, medical health staff on medication reconciliation. We have improved the percent of our reconciled medication from 7.3% to .5% and our number of un-reconciled medication from 50 to 15.

We've also been working our Ambulatory Care in doing huddles before the clinics, between the house staff, interns and the attendings that are supervising and doing debriefs after the clinic is finished.

Mei Kong: So healthcare is going through some exciting, as well as challenging times. It is no longer business as usual. Our greatest asset, as well as our greatest impediment is our workforce.

So teamwork and communication are key to patient safety, patient outcome and patient satisfaction. TeamSTEPPS is never the end. It's a continuous journey and you have to keep pursuing, reinforcing and measuring.

We find that if we engage all levels of staff constantly, and keep this journey going, we will see success. So thank you so much.

Abdul Mondul: Thank you.

Corinne White: Great thank you both very much for that really interesting presentation. At this time we would like to invite questions. Again, if you have questions, please enter them through the Q and A tab in Live Meeting. We'll give just a minute for people to get their questions in.

Also, if you'd like to ask a question and are only with us on the phone, please press 1 and then 4 on your phone. Operator, do we have any questions on the phone at this time?

Operator: No, I have no one who has queued up as of yet.

Corinne White: Thank you. Again, we ask that you ask your questions through Live Meeting. The Q and A tab at the top is your resource for those questions. We are happy to address questions to presenters and I’m sure that they would be happy to answer them.

Alexa Doerr: We do have one question.

Corinne White: Okay Alexa, go ahead then.

Alexa Doerr: Okay. How are you getting M.D. champions?

Abdul Mondul: For us, in Lincoln, when we did the first master training session, we included our chief medical officer, so our CMO is actually trained, master trained in TeamSTEPPS, and several chiefs.

Once you get a group of leaders from your medical staff going through the training, it is very easy to buy into the program. The TeamSTEPPS concept, you know, initially when you talk about TeamSTEPPS, they really don't know what the program is about.

Once they sit through the training, they understand how important and how effective this could be in improving patient safety within the organization. So we did it that way.

The other component for engaging staff is when we identify opportunity for improvement; usually the leaders of those areas are involved.

When you go to labor and delivery, you are identifying issues with shoulder dystocia, you are involved in the chief of that area and thinking that teamwork and communication will improve on those outcomes and working as teams to prevent medical errors.

So I think that's been very important. We actually trained all of our health staff, and all of the residents. In Lincoln we have six CME credited training programs.

We have approximately 260 residents and we go through TeamSTEPPS training with all of them. Then we do re-training once we get them involved in a specific project.

Mei Kong: From a corporate perspective, when we started this program, we actually required some of the physician involvement to be part of the team. For my purposes, I would not conduct a team without physicians.

For some reason, you know, the word went out and we have physicians knocking on my door saying I want to be participating in this because I heard it was a great program.

So I think that, you know, the theory of if you build, they will come, sometimes will work, but also the outcomes that they're seeing in various teams are engaging other individuals into this process.

Alexa Doerr: Great. We have other questions. How did you deal with the nay sayers and no, no's?

Mei Kong: With the nay sayers and the no no's, again we asked them to, join us. Some of the nay sayers and no no's are because they've been there for a long time or they don't have the time to go to a TeamSTEPPS master training program.

So we actually customize some of the programs to meet their needs and did sort of like a focus group before the TeamSTEPPS training to see what do they identify as issues in their units.

At the end of each focus group, guess what they say? Communication and teamwork, so I think incorporating them in the planning process engages the no no's, and also the fact that we customize it to their needs.

Abdul Mondul: Another component that we dealt with no no's. When it's a front line staff member that is involved in a particular project in an area in which we've done our, you know, four main basic modules from TeamSTEPPS.

There's some resistance. There are some not adapting very well to the project. We actually put them through the master training program. So that's why I mentioned, you know, we train some master trainers not to be trainers, but to buy in a little more into the system and the programs.

Alexa Doerr: Great. The next question is have you implemented across the entire hospital, both clinical and non-clinical?

Abdul Mondul: We have done a lot of cross training at Lincoln and some of the area that we've trained, we've trained risk management staff. That has been very important.

Also utilization management, quality management that they're reviewing our records and how to work in teams, how to communicate when there is a fall out that they find when they're doing chart reviews.

I think that has been also very effective. We have trained managers from different areas, like radiology and some other areas, again to improve the communication and it's been quite effective.

Mei Kong: From a corporate perspective, we also train various facilities at the same time. So it's not only cross training within the facility. Since we have 22 various facilities, we actually invite them to come and then they share their stories.

I think that really helps them see things in a different perspective. That's including, you know, human resources, your administrators, your social worker, you know, all levels of staff, including housekeeping.

Alexa Doerr: The next question is how did you address the culture of which nurses can express concerns?

Mei Kong: Well we have implemented the just culture. We recently invited Heidi King and David Marx to connect the dots a little for us. But allowing them to speak up and teaching them the two challenge rules, as well as the CUS, helps them to speak up but also developing an environment where they feel safe.

We also have a lot of anonymous calling. So if they feel uncomfortable in saying their name or identifying themselves, we have various systems in the facilities.

One was an anonymous phone call that they can leave a concern without leaving their name and the other piece is the computer system which we call CSI where they can log in from any computer and put in their concerns and get a code so that when they get a response, and it's all anonymous.

Abdul Mondul: One important component is also having the support from the top, from the leadership. So we talk about just culture in our town hall meetings. It comes in leadership meetings. It comes in staff meetings.

We are supporting - this is how we're doing business here and we are supporting a just culture and open reporting and voluntary reporting.

Corinne White: Great thank you. We are going to move on right now, but we will hold the remaining question for our general question and answer session later.

If you do have remaining questions, please ask them in the Q and A tab. Again, we ask that you type out the entire text of the question so that we can see what the question is.

At this time our next presenters are from the Christiana Care Health System. Let me get to the next slide. Carol Kerrigan Moore is a Safety and Quality Education Specialist in the Office of Quality and Patient Safety at Christiana Care.

She is responsible for designing and evaluating curriculum related to systemwide quality and safety initiatives and for facility improvement and teams.

Carol holds a BA from the University of Virginia and a Master's in Nursing from Pace University in New York.

Doctor Nicholas Gagliano is an Anesthesiologist at Christiana Care and Clinical Director for the Department of Anesthesiology. He serves on the Christiana Care Patient Safety Committee. He holds a BA from Hamilton College and an MD from The University of Rochester.

He completed his residency training and the University of Virginia. He also previously served in the US Air Force as a Chief, sorry, as Chief of Flight Medicine.

Carol and Dr. Gagliano have facilitated team training implementation activities, along with their interdisciplinary team colleagues in high risk, high acuity areas at Christiana Care to promote patient safety since 2006.

They are both TeamSTEPPS master trainers. Thank you very much for joining us. The floor is yours.

Carol Kerrigan Moore: Okay, it's my pleasure to be here with a lively group of people who have been involved in our implementation activities here. Just a little bit about Christiana Care.

We are headquartered in Wilmington, Delaware, two hospital campuses. We're Delaware's only Level 1 trauma center and we are a regional referral center.

We have about 10,000 staff, almost 1,500 medical/dental staff members and 240 residents and fellows.

Our surgical volume is ranked 19th in the nation and 10th among hospitals on the East Coast for total surgical case volume and our surgical trauma volume averages between 3,500 and 4,000 cases per year.

So without further adieu, I'm going to turn this over to some of my colleagues who will talk about our efforts in trauma, followed by the OR here and then completing with an effort in OB.

Brent Passarello: My name is Brent Passarello. I'm an ED physician and I've been a member of our Implementation Team for TeamSTEPPS since 2006.

We were in the process of our initial implementation and we were fortunate to gather kind of a multidisciplinary team that involved not only emergency medicine, but anesthesiology and surgery and nursing.

As we attended the first conference in DC in 2006, we were searching for an implementation area that would allow for some ultimate goal spread of the TeamSTEPPS culture throughout the organization.

We decided on trauma for several reasons. One, it involved many disciplines in care. We saw it as a focused area that involved not only the ED, but also surgery, anesthesia and nursing.

So we kind of took a narrowed approach initially in our focus and we built off the experiences from trauma, which other people will talk about.

As Carol mentioned, the kind of the inherent nature of our trauma program led to some areas for improvement. We had a two-tier trauma response in our organization that as a, what we call a trauma code, which is a surgical run response.

We have a trauma alert response, which is an ED run response and the natures of those two responses led to gaps in communication and to the responses that we recognized as an organization that really were in need of refinement.

The TeamSTEPPS model was a great building block that we used to address some of these areas.

So we began, as the slide depicts, training primarly in the emergency medicine, anesthesia, trauma arena. We trained over 300 clinicians initially and we focused on some core concepts of leadership, overall team performance.

With the goals of promoting the leadership, organization and the pre-arrival period, emphasizing readiness and anticipatory guidance, direction of care, you know, team oversight.

One of the big areas we also focused on was kind of the crowd control. We were seeing, you know, multiple providers, some of which had little role in the actual resuscitation kind of, you know, waiting to see if they had any active role.

It was leading to noise issues and communication issues in the bay. We addressed that through education and some other steps which we'll go through as we go through the presentation.

We developed some model that helped make sure people understood their -where they were supposed to be, who was supposed to be in those roles. We stress call outs, repeat backs.

We developed what we call the microphone practitioner, which if you're looking at the slide, it's Position 3 on that model where that is a resident who has a primary job of calling out findings so that only one person is speaking at a time. It really helps reduce noise and communication with the documenting nurses that were in the bay.

We stretched this whole stopping the line, which in our bays we literally have a red line where there are sterile precautions you're supposed to adhere to, and really anybody in front of that line must have an active role.

So those were the initial applications. Some of the tools we developed were again focusing on the pre-arrival brief. We started with this kind of hand-held card. It's posted in our trauma bays.

It really provides a framework for the leader to conduct the pre-arrival brief. Information was gathered. We developed a medic checklist. We disseminated that information to our medics where there were core or key bits of information that we wanted to be provided in the pre-arrival period.

So then, the appropriate equipment and staff needs could be addressed in that pre-arrival period. This tool helped people have a little checklist that they could run through and make sure they had what equipment and staff were going to be needed in that pre-arrival period. So the people were better prepared to deal with the patient as they arrived.

In that slide, as you can see, the other thing we really focused on, again due to the kind of the inherent nature of our trauma responses, particularly in a trauma alert setting where EM is the primary care giver, there are handoffs that are inherent.

What we call the post-resuscitation period involves the primary and secondary survey before that patient kind of gets transferred onto the imaging outside of the trauma bay.

There was an inherent handoff that exists in our system and typically at that point, after the primary and secondary survey where the patient is going to be moving on to imaging, the case is being handed off to the trauma for, you know, in the great majority of cases.

We worked, and still are working on closing those gaps that exist so that the trauma attending or the chief's are aware of the current status, what the preliminary plan of care is for that patient.

In that case then, those communications are held. We've worked diligently to try to close the attending to attending gaps that existed in our system and we've done that through cell phones and other technological tools that we're using to really close that gap to allow for streamlined efficient care.

The response afterward, because as many of you deal with, we deal with boarding. We want those patients, particularly that are coming back to the trauma bay from imaging back to the emergency department have a closed loop of communication.

So the post-diagnostic communication involves trauma attending to ED attending communication so that they're updated on what injuries were found during CAT scanning or imaging. What the plan is as far as disposition and ongoing ED needs if that patient were to board in the ED.

We did a survey, I don't know what year this was, maybe 2007 or so, to get a little sense of what we've accomplished. Again, the main focus of this was to just get a sense of the impact that his program has had on the culture.

There were inherent, I don't know, gaps in perception of each team's performance. We were pleased to see that overall this project was having good impact on the culture of our organization, particularly in the surgical realm.

Workload and distribution of tasks had a dramatic improvement from the surgical perspective. The ED perspective of the nature of it was that the trauma alert is an area that we focus on diligently in trying to understand each other's roles and close those cultural gaps.

Nursing again as you can see and anesthesia, again a number of tools, handoff tools that we developed to deal with those patients, those high priority patients that are going directly from the trauma bay to the OR.

We've done a lot I think to improve the perception of team and preparedness. We have worked in sustainment primarily in my role in the trauma bay through simulation.

We have now a monthly conference that is built into our trauma curriculum that focuses on high fidelity simulation. We have a wonderful VSC facility here, our virtual simulation center that allows us to conduct cases that we build off of from either live cases or sometimes just based on system issues that we feel we need to address.

It gives us an opportunity to address not only the clinical issues, but also again systems issues and communication issues. So we've developed cases on a monthly basis that allow us to conduct live simulations.

We piped the video into our trauma conferences that have, you know, roughly 40 or so attendees on a monthly basis to go over these cases, watch live simulation and then develop a debrief based upon the team's performance. To critique what went well, and what did not go well.

We also used live tape. We had the privilege here of videotaping our actual traumas. We use those tapes again in a QI performance improvement model to again show live video of what - how the teams are performing.

Overall it's been a fantastic way for us to continue to train and to stress the importance of the TeamSTEPPS model.

We do training on an ongoing basis. We annually train all our incoming emergency medicine, surgical, nursing and trauma practitioner staff. We do that in July when residents arrive and when the new nurses are coming on.

We train our incoming EM attendings to give them a perception of what we're trying to achieve and give them a little background on where we were. We again go over videotaped resuscitations.

We developed a tool which we found very helpful in trying to limit crowd control. We have a sign model; it's a badge scan system that sits outside of our trauma bays. People will come and they'll literally click on a touch screen and then scan their badge.

Then they're into that role so that people can see when all roles are filled so we can limit that crowd control issue and noise reduction.

It also helps facilitate names. We have a big staff and it's difficult, particularly on the nursing end, to always know who is who. So we find this to be a helpful technique.

It also posts as we collect that pre-arrival medic report we provided to our clerks who type in a framework so that it's not the constant what's coming in, what's coming in. People have a visual. The screens are posted in the trauma bay on an electronic basis and people have a background of what it is that's coming in, again to stop the interruptions, particularly involving the leader.

Carol Kerrigan Moore: Okay, I'm going to talk to you for a few minutes about what is happening here in the operating rooms. I'm going to turn this over to Dr. Gagliano to start that talk.

Nicholas Gagliano: Hi. Thanks for having us on this conference call. What we started out in the operating rooms, after some successes we had in the emergency department was, as Brent had said, initially we thought we would go straight to the operating room after we came back from TeamSTEPPS.

We realized that the operating room environment involves a bit of a greater challenge than we were ready to take on. So once we proved some successes in our emergency department and trauma realm, we move on up to the operating room.

What we were looking for is we were looking for a way that we could share what was going to happen in that operating room with everyone who was there.

Often times the only way you knew something in the operating room was going to be different then the posted case is when you saw three or four surgeons from different specialties involved.

We didn’t think that was necessarily the best way we developed care and delivered in order we think it was best for the people in the room to take care of that patient who was relying on everybody to have an idea of what was going on.

So as Mary Salisbury told us numerous times in the TeamSTEPPS training, our goal was to know the plan of the operation, share that plan in the operation with all the involved folks and then review the risks involved so we could best take care of that patient.

We, like every other large operating room who's incredibly busy, were looking at ways also to increase our efficiency and the safety we provided to our patients.

So we thought providing a structured framework would give us the best ability to do that.

Sometimes in operating rooms, with multiple surgical procedures going on or multiple parts of procedures, we need different instrument trays and sets of instruments.

We thought this was going to be a way to provide us what the surgeons needed to take the best care of that patient.

In the Joint Commission's goals for us to do a time out process before every operation as well, we thought that the TeamSTEPPS process and development of a tool for communication would allow us to complete the regulatory requirements in an environment where we could share further information.

What we did initially is we put a team together like we did in the emergency department. As the folks spoke before about the nay sayers and no no's, what we did is we put a team together that had technicians from the operating room, had nurses from the operating room.

It had people from anesthesia involved, had surgical attendings as well as some performance improvement folks from the organization.

We also used what was unique for us at this time. We used an executive coach to help us out because we realized that like everybody else, just because people go to TeamSTEPPS training doesn't mean they're going to be great trainers or great team members. So we used some coaching processes as well.

Which speaks to that, a team of experts is not an expert team. So we were bringing a bunch of smart people together, but we really wanted the teams to be experts.

We noticed in our operating rooms often times we, like everywhere else, we have new surgical residents coming in. We have a new anesthesia staff all the time and new nurses.

We noticed that folks were getting together to take care of patients in critical situations, yet didn't even know maybe who was on the team. Or didn't know their name and we thought that allowing introductions would allow those folks to know who was on their team, as well as probably better share information if everyone knew each other's name or at least knew who they were.

We also knew that we didn't, even though in our best teams we had the greatest communication and everyone in that room knew what they were doing, as well as what everyone else was doing. We didn't feel that we had a very formal or structured process to do that, both pre-operatively, inter-operatively as well as post-operatively.

So what we did is we were assisted by the World Health Organization when they came out with their surgical checklist. Like everything else with TeamSTEPPS, we felt that we needed to make this a Christiana Care document.

This was something that our folks could relate too, and not just necessarily something that came out of a paper or something that came out of a national program.

We felt that people would better receive what we did if it were based on what our needs were. So we incorporated some specifics of our institution, made sure we met regulatory requirements and came up with this surgical safety team communication.

As you noticed, it's broken into three parts. One is the preinduction of anesthesia part. Then there's a pre-surgical incision part and then a before the patient leaves the room part.

If you'll look, we also color coded it based on the specialty who was supposed to provide the information so that everyone had an active role in providing information during the process.

We also broke it into the pre-induction of anesthesia that was going to be a led by anesthesia portion. So there was some ownership from the anesthesia part.

There was the ownership for the surgical part and that second portion, which was led by the surgeon and then the third portion, which was led by the circulating nurse in the operating room.

So just like our team, we gave everyone a great responsibility to promote better teamwork.

Carol now is going to speak to some of the challenges along the way and how we got to where we are today.

Carol Kerrigan Moore: So just to quickly summarize, we began this process by participating in the Institute for Healthcare Improvement sprint to implement the surgical safety checklist in one OR for one patient on one day.

Then we went way beyond that and ended up pursuing that as a way to get focused feedback from the staff and the clinicians in the OR about what things made sense and what things needed to be added to that checklist.

Through piloting at three different sites, we were able to make a comprehensive list that was not so detailed to be specifically customized to each and every surgical procedure, but still had broad categories that were relevant across the system.

We then had all those posters placed in each OR and also did some smaller laminated versions for people to refer to in the OR itself.

Most recently we have taken this to the next step, and are moving forward with some additional pilots to strengthen the use of the checklist and hand off communication.

We have created videos to demonstrate processes specific to Christiana Care using actual Christiana Care staff and clinicians to make it real.

We also on the initial roll out of this, did have over 21 sessions to get to all the staff in all four of our sites and had some robust training with people who we had sent out to TeamSTEPPS training at some of the other sites that were offering it.

We then placed all these materials on the perioperative services internal Website for quick reference. It also facilitates new staff orientation for the staff development specialists and others who need to be oriented to how we accomplish this here.

Initially when we did some pilots, we got some feedback from people using the checklist. This was a big selling point because people did discover that they found out about things that they didn't know about otherwise and might not have known about.

I just listed a few examples here for you, allergy, antibiotic administration, pick list updates, which was a surgeon satisfier. That was feedback that we got specifically from surgeons about being able to use the third part of the briefing to talk about anything they didn’t have that they would like to have on their list for subsequent cases and then any equipment issues.

We also surveyed patients because a lot of pushback we got initially from clinicians was we don't want patients to feel like we don't have this under control and we're a little worried about talking about this in front of them.

But when we actually surveyed patients, they all felt that the surgical team's review of the safety checklist make them feel safe.

We also did a survey post-implementation after six months and this was based on a valid survey tool where we used questions from a tool called (ORMAC). You can see here our results.

For those of you who are in this process, you know that getting any type of consensus above 10% on a behaviorally changing element like this is good. So we were pleased to see that greater than 60% of the people felt that the checklist and the team training that went along with it had in fact improved communication.

Luckily only one of our nay sayers or two felt that it was worse. This also was very telling where respondents noted that they had been made aware of the patient specific clinical issues that they might not have known about otherwise.

That was over 45%, as you can see here and that translates into a huge number of opportunities in terms of keeping patients safe in our care. So we'll be looking to understand that more as time goes forward with our next steps.

Currently we have a team that is a subset of one of our perioperative executive committees. On that are Dr. Thomas Bauer, Dr. Kathleen McNicholas, Dr. Gagliano who you heard from previously, myself, Debbie Gigliotti who is from one of our OR sites and is a Nurse Manager. We have an ad hoc member, Beth Fitzgerald who helps us with simulation and video activities.

That team has taken this to the next step to really begin to further refine the ideal OR team environment. That's a surgeon-led effort. It has so far resulted in us producing the videos I referenced earlier.

We've done some initial training now with people who will be in the thoracic surgery service line. We're piloting this in one service line first and then expect to spread to some of the other ORs.

We've conducted pre, and we'll be conducting post implementation observations of elements of team behavior in the ORs to identify improvement over time.

We hope to, if we spread this more widely in the organization we would expect it to have a direct impact on both patient safety and efficiency and would be looking at some of our NSQIP and SCIP measures to see what impact that is having as well.

Just one last word about obstetrical care: this was implemented slightly differently in that we became consultants to some of the OB teams as they were also working on shoulder dystocia, the rare emergency that requires very effective team action.

So that has been now embedded again through our simulation training activities. It has been integrated into the shoulder dystocia clinical drills and it has also now becoming advanced to other OB emergencies.

It has supported development also of OB specific rapid response team development. So I will leave you with that thought and just our lessons learned in all of these areas, I'll let Nick chime in for that.

Nicholas Gagliano: The key is we - the folks who spoke previously about how do you get folks involved. I'd be remiss if I didn't mention other people who are in the room with us today.

This is just a small group of the folks involved. We have Pam Woods who's been Trauma Nurse here at Christiana Care and extremely involved in the trauma process as well as this TeamSTEPPS process through the emergency department.

We have Dr. Glen Tinkoff who really is the father of our trauma program here, even though he may not think so. He also was incredibly important in developing our statewide pre-hospital first responders system, getting us helicopters for our trauma system and holds a senior leadership position in the Department of Surgery.

We have Dr. Kathleen McNicholas who is a reformed cardiac surgeon become senior leader in the performance improvement patient safety realm of our hospital.

We have Dr. Bauer, who you heard Carol mention, who is one of our thoracic surgeons that really is trying to utilize this to provide the best environment for his patients. We like when surgeons come to us and ask for that kind of ability for us to be involved, and also Beth Fitzgerald who you heard about whose one of our nurse intern teachers and also affiliated with our simulation center.

Really, the reason we've had such great success is because we've had great leadership physician involvement and support of these processes. Without Dr. Tinkoff in the ED, we wouldn't be where we are today; without people like Dr. Bauer who’s come forth from the Department of Surgery, as well as the support from the surgery chairperson.

We wouldn't have that kind of support. So really what we're looking at here, and Carol what said, we needed this cooperation from all the folks involved and we needed to follow our policy.

So really, it gave us a great opportunity to take a close look at our policies and make sure that they were aligned with the principles we were teaching.

We're trying to change culture and we know that takes a really long time. But we feel that through example we'll be able to provide a better culture for all of our patients who come to our hospital, not just in the environment in which we've done these TeamSTEPPS lessons.

We've had great leadership support, as I said. We're continually looking at ways that we could critique and review our processes to say are we doing the right thing? And are we pushing the bar in the direction we want it to go?

Really we're looking at ways to measure it, not just beyond the behavioral. But can we make a difference in the lives that we save? We really think we do by having better teams and by having better sharing of information.

That's always a hard thing to prove and even though we do take care of 40, 50 thousand surgical patients a year, it's still a hard thing to prove because of the numbers that you need.

But we believe that eventually we will even move that bar and ensure that we are taking safer care of our patients. Thank you very much.

Corinne White: Thank you both very much for your presentation. We will go ahead and do the questions for Christiana Care at this time, Alexa.

Alexa Doerr: The first question is how did you get buy in from your trauma surgeons? Were they employees of the medical center?

Nicholas Gagliano: We actually, I'm going to put Dr. Tinkoff on the spot who is right here. He could speak to that and probably give you a better perspective.

Glen Tinkoff: I would argue that trauma surgeons have been doing this for a long time. We're trained in ATLS. It needed refinement and, you know, we were involved in the initial establishment of this process.

One my colleagues was in that team, that initial team and brought it forth. Also Nick talked about leadership. Fortunately I was in the leadership role.

The trauma surgeons are either contract or in my group. So they are going to do this and they did, and they have been - it's been effective.

Our biggest problem was, and to some degree still is, the resident workforce as it is an itinerant workforce that moves in and out, and getting them trained and queued up because they do a whole host of things in these trauma resuscitations.

They're the ones in the trauma bays at 3 in the morning and we have to watch the behavioral issues. That's where video, live video comes in and we've also established a DVR link so I can sit in my office and watch the trauma bays when they're active.

Brent Passarello: We've had great buy in and as Dr. Tinkoff says, you know, a lot of the trauma surgeons were sort of on staff here at Christiana Care. Everyone may say well it's easier to get a surgeon on staff to listen and to participate.

But most of our surgical staff is not employed by the hospital, the great majority. Yet, and you may think that typically I'll pick, not to be pejorative, but pick a group of surgeons. The orthopedic surgeons tend to not necessarily follow direction very well.

But we have had, even in our orthopedic operating rooms, now granted, we did have some more challenges sometimes than not. We have had our orthopedic surgeons become champions and participate.

It's about taking care of their patients and I think what we always try to do is we always try to frame it in response of “We’re just looking to take great care of your patients, doctor”.

It's very hard for physicians. We're all big ego driven folks. But it's very hard to argue when someone say's they're doing something in the best interest of your patient, as well as to get your day to be nicer and better.

I think it's very hard for us to come back again to that. So we've been lucky. But we've also had some great champions.

Alexa Doerr: Great thank you. Then next question is will you be willing to share project plans that other organizations could use and adapt to their organizations?

Carol Kerrigan Moore: Everyone seems to be looking at Carol. So I'll answer that question.

Brent Passarello: She's the planner.

Carol Kerrigan Moore: Well we informally shared a lot of our efforts, but both formally through TeamSTEPPS consortium meetings and also people tend to call us a lot because they know us from being out there at some of those venues.

So if people can be more specific about, you know, we certainly had a plan in place and we have a summary of how it all happened. I have lots of resources that we certainly would be willing to share in terms of our implementation plan here.

So I think my contact information is available at the end of the Webinar.

Corinne White: We don't have it queued in. But if the people have specific questions and they would like them forwarded on to our presenters from today, you can send an email to TeamSTEPPSswebinars@air.org.

That actually goes well with the next question which says will there be specific measures that these organizations will share with us?

The two organizations that you've heard from today, I don't think plan to share any specific measures. However, the next TeamSTEPPS Webinar should be about measuring the impact of TeamSTEPPS and I believe that is slated to include some specific measures.

So again, if you have a more specific question about things like guides or what kind of project plans you'd like to see, please pass them on to TeamSTEPPSswebinars@air.org.

Alexa Doerr: The next question is regarding the assignment of roles, which discipline initiates the briefing and time out process?

Corinne White: We couldn't hear that question because the connection broke up a little bit. Could you repeat that please?

Alexa Doerr: Sure. Regarding the assignment of roles, which discipline initiates the briefing and time out process?

Nicholas Gagliano: If you go back to our slide where it shows the surgical safety team communication. We no longer have control to back up to it.

But we broke it up into the three phases and we have different groups initiate the phases of the process. So anesthesia initiates the first phase because generally we're the folks in the room.

Even though we ask for the surgeon being present in the facility, they may not be physically present right in the operating room at the time.

But in the second portion, which was the classical time out right here, this slide, the classical time out before surgery. That's a surgical led portion because we feel the surgeon who is wielding out of the sharp knife or needle for the procedure is the one to be best prepared to lead when that's going to start.

Then at the end we though it was best for the circulating nurse whose doing the important parts of the surgical procedure, the counts for instruments, sponges, as well as labeling specimens and making sure they're correct.

Then comes the getting the correct procedure listed and all the documentation that needs to be done. We thought they were the best to lead that portion, once again giving everyone in that operating room some period of great responsibility in initiation.

Then the color coding – you can look at those little dots in the bottom right-hand corner, the yellow, blue and green. Those parts of the color coding of the communication are parts where you would expect the communication to come from that color-coded individual.

So the yellow being the anesthesia would communicate in the first part that the monitors are applied and functioning and the equipment and safety check is complete.

No special airway concerns in the antibiotic initiation and if follows for the other groups as well.

So even though one special team may lead one part of the brief, each specialty has a position in the briefing process to communicate. As well as we, you know, at the bottom state that at any point during the safety communication, if somebody feels that there was an omission or needs to add more information, by all means they're allowed to go ahead and do so and actually we condone that behavior.

Corinne White: Great thank you. That looks like the last question we have for right now through Live Meeting. Operator do we have any questions queued on the phone?

Operator: No. I have no one queued up.

Corinne White: Thank you. Again, if you have a question we ask that you use Live Meeting as your primary resource. If you do not write text in your question, we cannot answer it. So please make sure that you write some text rather than just using the hand raise icon.

We had planned to have three speakers for today. Unfortunately it looks like Doctor Dennis Allin from the University of Kansas has been pulled away unexpectedly for an emergency. So he will not be able to present today.

Given that, we'd like to open the floor for general questions about TeamSTEPPS. In addition, we also have two quick poll questions that we would like to ask.

This gives us an opportunity to know how we're doing and how the Webinars are going. So if Alexa, you would take care of those please.

Alexa Doerr: Absolutely. The first question is how useful was the information presented here today to you?

Corinne White: We'll just give everyone a minute or two to respond. We always joke that if you're in a group of people sharing a computer, whoever gets the computer first gets to answer. Or you can collaborate on your answer.

Then Alexa, once they've stabilized go ahead and close them and show the results.

Alexa Doerr: Okay. I'm going to go ahead and close them.

Corinne White: It looks like everyone found it useful. So thank you very much for that feedback. We really appreciate it. We have one other quick question.

Alexa Doerr: This question is would you recommend this Webinar series to others?

Corinne White: While we're doing this, it looks like we do have a couple of questions coming in. This question says are master training course offered - still offered? If yes, how often?

I do not know offhand the frequency. However I do know that they are absolutely still being offered. The best way to get more information about that would be to contact the Project Director, Deborah Milne.

Or there is another team Web address that you can use and that is TeamSTEPPSscontact@air.org. That's a good way to find out about the training opportunities and find out what it takes to get to a master training session.

Alexa Doerr: Okay and I've closed this poll. I'm going to show the results.

Corinne White: Everyone who voted would recommend. Thank you very much. We will move back to slides now.

Again, if you have any questions, please put them in the Q and A tab, and we'll have the presenters answer them if any should come up.

We have reached the end of our Webinar and I'd like to point out a few additional resources that are available. The first one being the TeamSTEPPS Website: This is on the AHRQ Website.

It has lots of good information about TeamSTEPPS. It has more information about the Webinars, lots of information about the National Implementation Project. It also contains tools and materials and other implementation stories.

The second Website that we would recommend is the DOD TeamSTEPPS Website, for which the address is also listed on this slide. That provides some additional information about TeamSTEPPS and resources that the Department of Defense provides.

The next slide is a reminder of the points of contact to the AIR team should you have any questions about this Webinar or future Webinars or TeamSTEPPS and the National Implementation Program in general.

Please do not hesitate to get in touch with us. It looks like there are no new questions through Live Meeting. Do we have any questions on the phone?

Operator: No questions.

Corinne White: All right, thank you. Well then again I would like to thank all our presenters today for wonderful presentations. I'd like to thank everyone who joined us on the phone for being here.

Any future question that you have, or lingering questions you can forward to us via email at TeamSTEPPSswebinars@air.org.

A little plug for our next Webinar: our next Webinar is August 10 and Alexa will be sending out information about that in the coming weeks.

So again, thank you for the wonderful presentations. They've been very interesting and we really appreciate all the information you have shared with us. Have a good day.

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

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