Strategies and Tools

to Enhance Performance
and Patient Safety
 Introduction

Discussion
 How are patients harmed as a result of
medical errors?
 How can we prevent medical errors?
 What are the solutions?

…Improved teamwork and communications…

Ultimately, a culture of safety

Mod 1 06.2
05.2 Page 2
TEAMSTEPPS 05.2 2
 Introduction

Objectives
 Describe the TeamSTEPPS training initiative
 Explain your organization’s patient safety program
 Describe the impact of errors and why they occur
 Describe the TeamSTEPPS framework
 State the outcomes of the TeamSTEPPS framework

Mod 1 06.2
05.2 Page 3
TEAMSTEPPS 05.2 3
 Introduction

Teamwork Is All Around Us

Mod 1 06.2
05.2 Page 4
TEAMSTEPPS 05.2 4
 Introduction

OR Teamwork Climate and Postoperative Sepsis Rates

Length of ICU Stay After Team Training (per 1000 discharges)
18
2.4
16
2.2
Avg. Length of Stay (days)

14
2 50 Group Mean
% 12
Re
du AHRQ National Average
1.8 cti 10
on
8 Low Teamwork
1.6 Climate
Mid Teamwork
6 Climate
1.4
4 High Teamwork
1.2 Climate
2
1 June July August Sept Oct Nov Dec Jan Feb March April May 0
Teamwork Climate Based on Safety Attitudes Questionnaire
(Pronovost, 2003) (Sexton, 2006)
Low → High
Johns Hopkins Johns Hopkins
Journal of Critical Care Medicine

Adverse Outcomes Indemnity Experience

Pre-Teamwork Training Post-Teamwork Training
25
20
20
50% 50%
Reduction Reduction
15
11
10

0
Malpractice Claims, Suits, and Observations
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN

Mod 1 06.2
05.2 Page 5
TEAMSTEPPS 05.2 5
 Introduction

Introduction
Evolution of TeamSTEPPS
Curriculum Contributors
• Department of Defense • Hospitals—Military and
Civilian, Teaching and
• Agency for Healthcare
Community-Based
Research and Quality
• Healthcare Foundations
• Research Organizations
• Private Companies
• Universities
• Subject Matter Experts in
• Medical and Business
Teamwork, Human Factors,
Schools
and Crew Resource
Management (CRM)

Mod 1 06.2
05.2 Page 6
TEAMSTEPPS 05.2 6
 Introduction

Team
Strategies & Tools to Enhance Performance & Patient Safety

“Initiative based on evidence derived

from team performance…leveraging
more than 25 years of research in military,
aviation, nuclear power, business and
industry…to acquire team competencies”

Mod 1 06.2
05.2 Page 7
TEAMSTEPPS 05.2 7
 Introduction

Patient Safety Movement

“To Err JCAHO

is Human” National Patient
IOM Report Safety Goals TeamSTEPPS
Institute for
Healthcare Patient Safety
DoD Executive Improvement and Quality
MedTeams® Memo from 100K lives Improvement
ED Study President Campaign Act of 2005

1995 1999 2001 2003 2004 2005 2006

Medical Team Training

Mod 1 06.2
05.2 Page 8
TEAMSTEPPS 05.2 8
 Introduction

The Components of a
Patient Safety Program

Mod 1 06.2
05.2 Page 9
TEAMSTEPPS 05.2 9
 Introduction

Course Agenda
 Module 1—Introduction
 Module 2—Team Structure
 Module 3—Leadership
 Module 4—Situation Monitoring
 Module 5—Mutual Support
 Module 6—Communication
 Module 7—Summary—Pulling It All Together

Mod 1 06.2
05.2 Page 10
TEAMSTEPPS 05.2 10
 Introduction

Introductions and Exercise:

Magic Wand

If I had a “Magic Wand”

and could make changes
within my unit or facility
in the areas of patient
quality and safety…

Mod 1 06.2
05.2 Page 11
TEAMSTEPPS 05.2 11
 Introduction

Why Do Errors Occur—Some Obstacles

 Workload fluctuations  Excessive professional
 Interruptions courtesy
 Fatigue  Halo effect

 Multi-tasking  Passenger syndrome

 Failure to follow up  Hidden agenda

 Poor handoffs  Complacency

 Ineffective  High-risk phase

communication  Strength of an idea
 Not following protocol  Task (target) fixation

Mod 1 06.2
05.2 Page 12
TEAMSTEPPS 05.2 12
 Introduction

Institute of Medicine Report

Impact of Error:
Federal Action:
 44,000–98,000 annual deaths
occur as a result of errors By 5 years;
 Medical errors are the leading
 medical errors by 50%,
cause, followed by surgical
mistakes and complications  nosocomial by 90%; and
 More Americans die from medical
eliminate “never-events”
errors than from breast cancer, (such as wrong-site surgery)
AIDS, or car accidents
 7% of hospital patients experience
a serious medication error
Cost associated with medical errors
is $8–29 billion annually.
Mod 1 06.2
05.2 Page 13
TEAMSTEPPS 05.2 13
 Medical Errors Still Claiming
Introduction
Many Lives
By Elizabeth Weise, USA TODAY
05/18/2005

As many as 98,000 Americans still die each year because of medical errors despite an unprecedented focus on patient
safety over the last five years, according to a study released today. Significant improvements have been made in some Improvements
hospitals since the Institute of Medicine released a landmark report in 2000 that revealed many thousands of
Americans die each year because of medical mistakes.
Hospitals have taken steps
But nationwide, the pace of change is painstakingly slow, and the death rate has not changed much, according to the to reduce medical errors and
study in The Journal of the American Medical Association.
injuries.
The researchers blame the complexity of health care systems, a lack of leadership, the reluctance of doctors to admit
errors and an insurance reimbursement system that rewards errors — hospitals can bill for additional services needed Examples:
when patients are injured by mistakes — but often will not pay for practices that reduce those errors.
 Computerized
"The medical community now knows what it needs to do to deal with the problem. It just has to overcome the barriers prescriptions: 81%
to doing it," says study co-author Lucian Leape of Harvard's School of Public Health. decrease in errors.
The institute, a public policy organization, pushed key health care organizations to focus on patient safety, the new  Including pharmacist in
report says. As a result, reductions as much as 93% have been made in certain kinds of error-related illnesses and
medical team: 78%
deaths.
decrease in preventable
Computerized prescriptions, adding a pharmacist to medical teams and team training in the delivery of babies are drug reactions.
among the improvements medical centers are making, the study finds.
 Team training in delivery
But "we have to turn the heat up on the hospitals," Leape says. of babies: 50% decrease
For example, 5% to 8% of intensive-care patients on ventilators develop pneumonia, the study says. But by strictly in harmful outcomes —
following a simple protocol of bed elevation, drugs and periodic breathing breaks, those outbreaks can be reduced to such as brain damage —
almost zero. "A little hospital in DeSoto, Miss., called Baptist Memorial did it, so it doesn't take a big academic medical in premature deliveries.
center," Leape says.
Source: Journal of the American
Hospitals that eliminate infections should receive bonuses, Leape says. "If insurance companies paid 20% more for Medical Association
patients in (intensive-care units) where there were no infections, they'd cut costs substantially.

"We really need to rethink how we pay for health care. What we do now is pay for services, but what we should do is
pay for care and outcomes."

…little progress towards the goal

Leape and Berwick,
JAMA May 2005
Mod 1 06.2
05.2 Page 14
TEAMSTEPPS 05.2 14
 Introduction

JCAHO Sentinel Events

Mod 1 06.2
05.2 Page 15
TEAMSTEPPS 05.2 15
 Introduction

What Comprises Team Performance?

Knowledge Attitudes
Cognitions Affect
“Think” “Feel”

Skills …team performance is a

Behaviors science…consequences
“Do” of errors are great…

Mod 1 06.2
05.2 Page 16
TEAMSTEPPS 05.2 16
 Introduction

Outcomes of Team Competencies

 Knowledge
 Shared Mental Model

 Attitudes
 Mutual Trust
 Team Orientation

 Performance
 Adaptability
 Accuracy
 Productivity
 Efficiency
 Safety

Mod 1 06.2
05.2 Page 17
TEAMSTEPPS 05.2 17
 Introduction

Teamwork Actions
 Recognize opportunities to improve patient safety
 Assess your current organizational culture and
existing Patient Safety Program components
 Identify teamwork improvement action plan by
analyzing data and survey results
 Design and implement initiative to improve team-
related competencies among your staff
 Integrate TeamSTEPPS into daily practice.

“High-performance teams create a safety net for

your healthcare organization as you promote a
culture of safety."

Mod 1 06.2
05.2 Page 18
TEAMSTEPPS 05.2 18