Craig Bunnell, MD, MPH, MBA

Chief Medical Officer

Dana-Farber Cancer Institute

Boston, MA

Changing Culture for Good:

Disseminating and Sustaining Team Training in Outpatient Oncology Across an Academic Medical

Center and Community Satellites

Disclosure

I have no conflicts of interest to declare.

3

To provide expert,

compassionate care to children

and adults with cancer while

advancing the understanding,

diagnosis, treatment, cure, and

prevention of cancer and related

diseases.

DFCI Mission

Background• Multiple studies have found that 75% of errors occur because of

deficiencies in communication and coordination of patient care.

• Failures in coordination and communication have been associated with:• higher risk for error• increased mortality• longer hospital lengths of stay• higher staff turnover

• Poor communication and misunderstandings contribute to a culture of blame, isolationism, and lack of trust.

Background

Joint Commission Sentinel Event Statistics

Background

• The Institutes of Medicine and The Joint Commission have recommended implementation of team training techniques

• Such techniques have been applied successfully in various “contained” inpatient settings (e.g. ICU, ER, OR, L&D, etc.) but never in an outpatient or oncology setting.

The Science of Teamwork

• Based on 30 years of research (military, aviation, nuclear industries, more recently medicine)

• Defines a team

• Mitigates issues of hierarchy

• Identifies necessary skills for optimum team performance

• Relies on robust systems to support implementation of tools and agreements

• Involves culture change

Team Training Concepts (Crew Resource Management)

• Research for Army Aviation showed teamwork saved lives

• 5 Principles of CRM

• Asking for relevant information

• Offering relevant information

• Communicating and confirming proposed actions

• Advocacy

• Conflict resolution

What’s in it for us ?

Reduced ErrorReduced risk of harm

Decreased litigation exposureDouble check Better systems

Improved Quality of Life

Fewer distractions Less anxiety

Skills for organization Improved Work Environment Improved Work Relationships Decreased finger pointing

Decreased conflict Mutual trust

Improved Efficiency Fewer errorsFewer pages

Decreased wait timesFewer emails

Improved Patient Care

POTENTIAL

BENEFITS

Why Team Training in Outpatient Oncology?

• Chemotherapy process: most high risk/high volume activity in a cancer center (>150,000 infusion visits/yr)

• Treatment regimens complex, involving multiple drugs; standard and investigational (342 clinical trials)

• Treatment plans can be changed based on lab results

• Clinical team often separated by geography, making direct communication challenging

• Occurrence reports and ‘near miss’ data demonstrated opportunity to improve safety

The Intervention• Baseline data collection: staff surveys, safety reports

• Engage Leadership: kickoff meeting

• Observations, interviews with clinical staff

• “Train the Trainer” session and determine “pain points”

• Process Meetings: develop agreements, tools, system changes

• Train ALL staff

• “Go Live”

• Post-data collection

Strategy for Change• Mandate from Executive Leadership and Board of

Trustees

• Clinical leaders teach and lead

• Use performance data, actual ‘near-miss’ scenarios

• “Train the Trainer” methodology

• Project support: outside consultation, project manager

• Continuous measurement and feedback

• Refresher courses, trainings, video for new staff

• Learning Collaborative: to sustain/spread best practices

Dana Farber Cancer Institute - Team Training Dissemination: Initiation to Implementation

July 2008

Oct.2008

Jan.2009

April2009

July 2009

Oct. 2009

Jan.2010

April 2010

July 2010

Oct. 2010

Jan.2011

April2011

July 2011

Oct2011

Jan 2012

April 2012

Hematologic Malignancies (HEO)

Breast Oncology (BOC) Institute Pilot

Benign Hematology (HSC)

Neuro-Oncology (NOC)

Gynecologic Oncology (GYN)

Sarcoma Oncology (SAC)

Milford Regional Medical Center

South Shore Hospital

Gastrointestinal Oncology (GCC)

Head & Neck Oncology (HNO)

Melanoma (MEL)

Cutaneous Oncology (CUC)

Londonderry

Pediatric Oncology

Genitourinary Oncology (GUC)

Thoracic Oncology (TOP)

Planning Phase

Implementation Phase

Faulkner Hospital

Inpatient

Metrics

• Patient arrival to infusion area with no chemotherapy orders

• # of change orders not communicated

• Staff perceptions of teamwork, communication, safety and respectful practice environment

• Patient perception of teamwork (Press-Ganey)

• Wasted drug related to communication failures within team

Breast Oncology: Post-Implementation Unlinked Appt.

Unlinked Appointments - % of Total Patient Scheduled, Pre and Post Email Reminder, 2009

70%

87%

95%

74%

91% 90% 89%

82%

90% 92%

81%

89%

82%85%

89%

98% 98% 100%96% 96% 98% 99%

94% 96% 98% 98% 98% 96%99%

96%

0%

20%

40%

60%

80%

100%

120%

3/9 3/16 3/23 3/30 4/6 4/13 4/20 4/27 5/4 5/11 5/18 5/25 6/1 6/8 6/15

% t

o t

arg

et

% pts with orders (48hrs prior to appt) % pts with orders prior to patient arrival (after email reminder)

Availability of chemotherapy orders for unlinked visits increased from 70% to 97% and has been sustained

Breast Oncology: Reported Near Miss Events

1115 12

62

4

0

5

10

15

20

Pre TrainingAug-08 - Feb-09

Post TrainingMar-09 - Sept-09

Follow-UpMar-10 - Sept-10

Num

ber o

f Rep

orts

Breast Oncology - Safety ReportsPre and Post Team Training, 1-Year Follow-up

Unrelated to Team Training Related to Team Training

Main Campus: Reported Near Miss Events

Pre Training Post Training 1 Year Follow-up0

25

50

75

100

125

150

143

108

138

12

6

5

Unrelated to Team Training Related to Team Training

Nu

mb

er o

f R

epor

ts

DFCI Main Campus- Safety Reports Pre and Post Team Training, 1-Year Follow-up

Patient’s Perception of Teamwork: Satellite vs. Main Campus

Oct

-09

Dec-0

9

Feb-1

0

Apr-1

0

Jun-

10

Aug-1

0

Oct

-10

Dec-1

0

Feb-1

1

Apr-1

1

Jun-

11

Aug-1

1

Oct

-11

Dec-1

1

Feb-1

2

Apr-1

2

Jun-

12

Aug-1

2

Oct

-12

Dec-1

290.0

92.0

94.0

96.0

98.0

100.0

96.9

94.1

Press-Ganey: "Degree to which staff worked together to care for you"

satellite campuses Linear (satellite campuses)main campus Linear (main campus)

Pa

tien

t Sa

tisfa

ctio

n S

core

Team Training (TT)Survey Questions

MD, NP, PAn = 120

Infusion RNsn = 122

Support Staff

n = 230

Definitely/Probably

Has TT improved patient safety? 71% 79% 79%

Has TT improved the efficiency of patient care? 63% 72% 75%

Has TT improved the quality of patient care? 71% 72% 78%

Has TT helped staff to treat one another more respectfully? 67% 77% 67%

Has TT improved relationships among members of the care team? 61% 77% 70%

Has TT made it easier for you to ask others for help? 52% 74% 68%

Has TT made it easier for you to express your concerns to other members of the care team? 55% 77% 65%

Staff Perception of Teamwork

Chemotherapy Order Intervention Data

Pre Team Training Post Team Training

Random Sampling n = 1850 n = 1951

Order Changes Not Communicated

51 (2.76%)

34 (1.74%)

Lessons Learned: Critical Strategies for Dissemination and Sustainability• Support from Leadership: - Board of Trustee participation - Engagement of Executive Leadership

- Early engagement of day-to-day leadership- Patient involvement

• Engage the Front-line in Development, Planning, Implementation- Train-the-trainer- Implementation--balance universal change with flexibility

• System/infrastructure redesign to support changes/agreements

• Execute, Measure and Refine - Metrics

- Continuous feedback on team performance - Training plan for new employees - Periodic refresher course/iterative refinements

- Acknowledge/Share Best Practices