Introduction to Team Training

Colorado Patient Safety Coalition

Carol Anne Tarrant, RN, MS, JD Jeffrey L. Varnell, MD, FACS

Agenda
Are we doing as well as we can? Whats preventing us from doing better? Are there any models that we can incorporate? What skills & tools can we learn? Is there any evidence that all this will make a difference?

An Overview Aviation & Healthcare

Aviation & Healthcare Both Have Preventable Errors

Healthcare Statistics Regarding Preventable Errors

Healthcare research shows 70% of adverse events were preventable One study shows 54% of surgical errors are preventable Preventable errors cost $17 billion (IOM) ANNUALLY! 70-80% medical mishaps are caused by human factors issues related to interpersonal interaction

A Human Factors Expert Looks at Healthcare

No one in charge
Safety is not a corporate priority Failure to observe basic safety practices Tolerance of unsafe practices No systematic data collection No analytic response to accidents Reliance on training & punishment No training in safety, teamwork

Current Healthcare Mental Models

Hierarchy
One person responsible for knowing everything

Machismo
We can perform at maximum efficiency as long as needed

Personal blame
If something goes wrong, someone is to blame

Speed is supreme
Turnover time, etc.

Dictatorial communication
I only have to say this once! If I speak up, I will be mocked or belittled!

Task compartmentalization
Dont tell me what to do! Im only responsible for my area!

Case History
5:40 am - Pt. at 37 wks. gestation arrives at hospital with history of heavy bleeding 6:00 am - Attending notified, requests deck doc to evaluate Deck doc orders US; no sign of abruption, pt. still bleeding. Waits for attending to arrive. 7:00 am Attending arrives. Dx abruption. 7:36 am - C/S accomplished. APGARs 1,1,1; infant survives with severe neurological impairment.

Our Conversation
Why communication is the heart of the matter The limits of human performance Lessons from high reliability units Human Factors Skills
Briefings Time outs, pauses Assertion Its a hierarchical world! Situational Awareness Debriefing

Why Communication
The overwhelming majority of untoward events involve communication failure Somebody knows theres a problem but cant get everyone in the same movie The clinical environment has evolved beyond the limitations of individual human performance

What Happens Without Communication

NASA Simulator Study

One of the key differences between high performing crews & low performing crews the high performers talked more. One characteristic of ineffective teams is that when a problem arose, they simply stopped talking & communicated less.

JCAHO Sentinel Events

Communication breakdowns remain the primary root cause of more than 60% of the 2034 sentinel events analyzed. The majority of sentinel events (75%) resulted in a patient death.

Sentinel Event Statistics

Error is Inevitable Because of Human Limitations

Limited memory capacity 5 pieces of information in short term memory Negative effects of stress error rates
Tunnel vision

Negative influence of fatigue & other physiological factors Limited ability to multitask cell phones & driving Flawed judgment

Our Error Model Today

Trained to be perfect - knowledge & competence are equated with the absence of error Healthcare culture rewards perfection & frowns upon error Individual agency - fix the person & the problem goes away

Captain of the Ship vs. Team Leader

Knows everything Values & relies on input from other team Remembers everything members Is responsible for Recognizes limitations everything of workload, fatigue, Always does things stress, etc. my way Makes decisions based on all sources of info Sees value in consistent processes

Reoccurring Organizational Systems Problems

Communication
Shift reports, sign outs & hand-offs Inadequate, inaccurate information

Task fixation, task overload Assertion, escalation of communication Supervision, leadership

* MMI Company data of 250 hospitals over 10 years

Where Do Things Fall Through the Cracks ?

Systems information, tests, diagnoses Communication Hand-offs Failure of recognition Failure to rescue

Errors in Anesthesia
Human error accounts for 80% Failure to perform normal check Lack of proficiency with equipment Lack of vigilance, distraction Haste Lack of experience with technique
Cooper et al, Anesthesiology, 1984.

JCAHO Patient Safety Goals

Read-backs on verbal & telephone orders / test results Identify patient from 2 sources Verification of correct patient, correct site, correct procedure Briefings before procedures, operations Infusion pumps / monitor alarms Nosocomial infections Medication reconciliation / communication Actions to prevent risk of falls

Avoidance of Wrong Site Surgery JCAHO Standards

Patient to mark side of surgery Visit with patient pre-op & preanesthesia - sign your site Confirm with other information e.g consent form Time out in OR to confirm correct patient, correct surgery, correct side or level

COPIC Wrong Site Surgery Statistics 2000-2004

16 14 12 10 8 6 4 2 0 Occ2000 Occ2001 Occ2002 Occ2003 Occ2004

Wrong side surgery Wrong level surgery

First the Problem Now the Solution!

Lessons from Aviation Crew Resource Management

Focus on teamwork,communication, flattening hierarchy, managing error, situational awareness, decision making Non-punitive reporting of near misses, 500,000 reports over 15 years Very open culture with regard to error & safety

Team Training The Process

Needs assessment Measure of culture safety attitude questionnaires (SAQs) Training sessions multidisciplinary, interactive Observation & coaching onsite Follow up training sessions Development of protocols drills, debriefing sessions, simulations Follow up questionnaires (SAQs)

Team Approaches to Errors

Culture Communication Skills
SOAP for communication

Briefing debriefing Assertiveness skills Checklists Read-back Call out Outcomes: Errors, costs, turnover rates, satisfaction rates

Communication Skills

S Situation O Objective findings A Assessment P Plan for action & recommendations

Briefings Key Elements Checklist

Got the persons attention Made eye contact, faced the person Introduced self Used persons name familiarity is key ! Asked knowable information Explicitly asked for input Provided information Talked about next steps Encouraged ongoing monitoring & crosschecking

Debriefing
An opportunity for individual, team & organizational learning The more specific, the better What did we do well? What did we learn? What would we do differently next time ? Who is accountable to making sure any changes are made?

Helpful Hints on Assertion

Focus on the common goal: quality care, the welfare of the patient, safety its hard to disagree with safe, quality care Avoid the issue of whos right & whos wrong concentrate on doing the right thing De-personalize the conversation Actively avoid being perceived as judgmental Be hard on the problem, not on the people Implement critical language CUS

When Assertion is Difficult

Situational Awareness
The extent to which Team Members are aware of the status of a particular clinical event, patient status, or operational issues pertaining to the teams overall tasks & goal.

Red Flags Loss of Situational Awareness

Ambiguity Reduced/poor communication Confusion Trying something new under pressure Deviating from established norms Verbal violence Doesnt feel right Fixation Boredom Task saturation Being rushed / behind schedule

Expert Decision Making

Expert pattern matching against large mental library, quick, accurate if confirm correct answer Novice library is empty slow, error prone process Certain diagnoses are favoredfrequent, recent, serious Trial & error/personal experience

Human Factors
Briefings Appropriate assertion Situational awareness Debriefing Common mental model

Case History
5:40 am - Pt. at 37 wks. gestation arrives at hospital with history of heavy bleeding 6:00 am - Attending notified, requests deck doc to evaluate Deck doc orders US; no sign of abruption, pt. still bleeding. Waits for attending to arrive. 7:00 am Attending arrives. Dx abruption. 7:36 am - C/S accomplished. APGARs 1,1,1; infant survives with severe neurological impairment.

Communication Skills

S Situation O Objective findings A Assessment P Plan for action & recommendations

Characteristics of High Reliability Units

Preoccupation with failure Refusal to simplify Commitment to resilience Deference to expertise Sensitivity to operations

Plan for Action High Reliability Units

Policy & protocol development Safety attitude surveys Teamwork training & follow-up Regular interdisciplinary debriefings/reviews Review of operative injuries Simulator training on known hazards Patient safety position

Measuring Success
Patient injuries Team satisfaction Patient satisfaction Nurse / staff turnover Lawsuits & claims

Thank You!
Questions???