teamwork and transparency jill marsteller, phd, mpp david thompson, dnsc, ms, rn on the cusp: stop...

Teamwork and Transparency

Jill Marsteller, PhD, MPPJill Marsteller, PhD, MPPDavid Thompson, DNSc, MS, RNDavid Thompson, DNSc, MS, RN

On the CUSP: Stop BSIOn the CUSP: Stop BSITuesday, February 9, 2010Tuesday, February 9, 2010

Learning Objectives

• You should be able to – Explain transparency and the need for it in

this project– Describe importance of strong teamwork on

CUSP/CLABSI team and in unit generally– Provide examples of teamwork-enhancing

tools

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Transparency

• Make harm visible– Share stories – Discuss BSI rates– Link to patients

• Need to share data with – The unit– Executive partner– Board

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Transparency

• Track progress visibly – Bulletin boards that show improvements– Memos– Announcements at meetings– Milestone celebrations– Recognition of people’s efforts

• Frequent reminders, keep in the front of caregivers’ minds

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Percent Understanding Patient Care Goals

00.10.20.30.40.50.60.70.80.9

1

1 2 3 4 5 6

Residents

Nurses

Implemented patientgoals sheet

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Transparency’s Link to Teamwork

• Be open about issues and problems, challenges

• Confront the elephant in the room

• Be explicit about sharing a common goal

• Admit we all need each other

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Available Tools to Enhance Transparency

• Executive Senior Leader Checklist

• Infection Preventionist Checklist

• Weeks with CLABSI Banner

• Staff Safety Assessment

• Team Check Up Tool

• Central Line Audit Forms

Teamwork

• Effective communication– Closed loop communication/active listening – Responsiveness of team members– Communication skill set

• Situational awareness

• Shared mental model

• Mutual support

• Teamwork and communication tools8

Communication Breakdowns are frequently the root cause of…undesirable outcomes

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0

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20

30

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50

60

70

80

90

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% o

f res

pond

ents

with

in a

n IC

U re

port

ing

good

team

wor

k cl

imat

eTeamwork Climate Across Michigan ICUs

0

10

20

30

40

50

60

70

80

90

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% o

f res

pond

ents

with

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n IC

U re

port

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good

team

wor

k cl

imat

eTeamwork Climate Across Michigan ICUs

No BSI 21%No BSI 21% No BSI 44%No BSI 44% No BSI 31% No BSI 31%

No BSI = 5 months or more w/ zeroNo BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

Impact on Healthcare

• ‘Caregiver interaction’ aka effective teamwork– Reduced length of stay

– Lower nurse turnover

– Higher quality of care

– Greater ability to meet family member needs

(Shortell et al, Med Care;1994:508-25.)

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Impact on Healthcare

• Effective teamwork in ICU reduced risk of readmission or death--16% to 5% (Baggs, Heart Lung 1992;21:18-24.)

• Ineffective collaboration & communication in OR = retained sponges, mismatched blood transfusion & wrong extremity nerve blocks (Gawande, NEJM 2003;348:229-35. Edmonds, Reg Anesth Pain Med 2005;30:99-103. Gibbs, AHRQ report 2001;2557.)

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Percent Understanding Patient Care Goals

00.10.20.30.40.50.60.70.80.9

1

1 2 3 4 5 6

Residents

Nurses

Implemented patientgoals sheet

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Impact on ICU Length of Stay

0

0.5

1

1.5

2

2.5

Avg

. LO

S (

day

s)

ICU LOS

654 New Admissions: 7 Million Additional Revenue

Daily Goals

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• Skill requirements in teams:– Mutual performance

monitoring and adaptability

– Supporting/back-up behavior

– Team leadership

– Task-related assertiveness

– Conflict resolution

– Closed-loop communication

What Are the Required Teamwork Competencies?

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Strategies to achieve a “shared mental model”

Individual StrategiesSituation Monitoring

Group Strategies

Know the patient care plan Active listeningRead backVerifyCross monitoringSelf monitoring

BriefDebriefHuddleMeetingsDocumentationHand-offsCall Out

Environmental support

Visual management toolsChecklistsDistraction controlTechnology aids

What we can do to stay on the same page…

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• Members of the team have an understanding of “what’s going on” and “what is likely to happen next.”

• Teams are alert to developing situations, sensitive to cues and aware of their implications.

Situational Awareness

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• Focus is – Preparation/planning and vigilance– Workload distribution– Distraction avoidance

Situational Awareness

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Elements That Affect Situational Awareness

• Interruptions• Task absorption• Verbal abuse• Fatigue• Not following plan of care• Ambiguous orders/directions• Change in team member• Work load• Skill level

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• Know the game plan – through briefings and team management (e.g., workload & workflow management, task coordination)

• Anticipate next steps and possible events• Follow known policies and procedures• Cross-check and verify• Provide ongoing updates – call-outs, cross-talk,

and briefings• Implement team huddles

Improving Situational Awareness

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Team Huddle• Pulling together members of the team to

review patient data and decide on the course of action– Can be prearranged like evening rounds or as

needed when a patient’s condition requires a change in course of action

– May involve strategies to plan oversight, physician availability

– ANYONE CAN ASK FOR A TEAM HUDDLE, ANYTIME

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Active Listening

• Focused on the speaker

• “Actively” listening and processing the information being presented

• Used to retain information and gain knowledge

• Goal: The ability to repeat the sender’s message-“read back”

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• Process of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors– Mechanism to help maintain accurate situation

awareness– Way of “watching each other’s back”– Ability of team members to monitor each other’s

task execution and give feedback during task execution

Cross Monitoring

(McIntyre and Salas 1995)

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Call Out

• Statements of action or description of what you are seeing to keep people informed:

“The patient is experiencing runs of v-tach despite the medication…”– Can be used for routine care such as

checking an alarm– Can be used during a procedure or arrest

situation to let members of the team know what has been completed

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Briefing Defined

A briefing is a discussion between two or more people, often a team, using succinct information pertinent to an

upcoming event.

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1. Situation - Current situation that needs reporting

2. Background - Pertinent history and treatment

3. Assessment - Diagnosis of categorization of the current situation

4. Recommendation - Proposed plan of care

The SBAR BriefingSITUATION driven-Structure based

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Conflict Resolution Tools

• DESC script (Describe, Express, Specify, Consequences)

• Two-challenge rule

• Mediation

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What makes up an effective team?

Effective Team Members

Effective Team Leaders

Healthy and productive interactive process

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Another way of looking at it

Effective Team Members

Effective Team Leaders

• Any team member may be called upon to be leader in a given situation/or subpart of the effort.

• Designated team leaders are always team members at the same time.

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Effective team member-leaders

Leaders• Organize the team• Articulate clear goals• Make decisions through

collective input of members

• Empower members to speak up and challenge

• Actively promote and facilitate good teamwork

• Assist in conflict resolution

Members• Understand their role • Agree on the goals• Provide input to

decisions, assert their case

• Speak up and challenge• Actively promote and

facilitate good teamwork• Be open to conflict

resolution

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Effective team member-leaders

Leaders• Share information openly• Act as role models and

cue team members to use teamwork skills

• Offer constructive and timely feedback

• Facilitate briefings, huddles, debriefs, and conflict resolution

Members• Share information openly• Use teamwork skills and

cue other team members to also do so

• Offer constructive and timely feedback

• Participate actively in briefings, huddles, debriefs, and conflict resolution

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Effective team member-leaders

Leaders• Initiate planning and

include team members• Delegate tasks

– What, to whom– State clear expectations– Ask for feedback

• Facilitate conflict resolution– Two-attempt rule– DESC script– Helping team members

practice techniques – Serving as a mediator

Members• Contribute to planning

process, initiate subparts of the plan

• Accept delegation, be accountable, provide feedback

• Practice and use conflict resolution techniques

• Mediate among coworkers informally

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• Ability to predict the needs of other team members/fewer surprises

• Decisions use better, complete information• Conflict management provides more pleasant

environment/fewer hurt feelings and grudges• Better accountability for team performance• Reduced stress on the team as a whole• Better experience for patients/improved

safety

Key Benefits of Effective Teamwork

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Available Resources to Improve Team Communication

• Science of Safety Video

• CUSP Toolkit: – Staff Safety Assessment– Daily Goals Checklist– Safety Issues Worksheet – Culture Check-up Tool

• Team Stepps

AHRQ Team Stepps

• http://teamstepps.ahrq.gov/abouttoolsmaterials.htm