implementing team training at duke karen frush, bsn, md chief patient safety officer duke medicine
TRANSCRIPT
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Implementing Team Training at Duke
Karen Frush, BSN, MDChief Patient Safety Officer
Duke Medicine
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THE JOURNEY
• PICU
• Peri-operative Services
• GSK Collaborative
• NCHA Collaborative
• Comprehensive Implementation across Duke Medicine
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Team Training: One more initiative??
• Time and workload– Adding one more assignment onto
everything else• Best model?
– Lack of data to demonstrate improved outcomes
– Many consultants and approaches• Required for all team members?
– Logistics: Shut down the ORs?• Cost vs benefit
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Teamwork Training ProcessPhase I: Pre-intervention
• Chose to work with consultants• Gathered pre-training data
– Knowledge test– Attitude: Sexton Teamwork and Safety Climate
survey– Behavior: Conducted Real-time Observations– Outcome data
• Processes• Clinical outcomes
• Analyzed Secondary Measures– Staff satisfaction and work culture– Patient satisfaction
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Teamwork Training ProcessPhase II: Training
• Unit leaders involved with planning and implementation (J Mericle, J Meliones, K Mistry)– 3 sessions to accommodate shifts
• Multidisciplinary group sessions• Physician, nurse, and human factors facilitators• Interactive session with hands-on tools• Feedback allowed for further development• Focused training for action at unit level
– Focused on tools and techniques to address unit’s issues
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Focused Unit Training Tools
• Handoff Communication– SBAR: structured language
• Critical Language– “I need clarity”: assertion
• “Sterile Cockpit”– Focused attention– Limit interruptions during Rounds
• Huddles for better planning• White Boards
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Teamwork training processPhase III: Implementing change
• Leadership role models• Multi-disciplinary (internal) coaches• Interval observations, coaching by
consultants • Active participation of consultant experts in
unit-based safety team meetings• Phone calls at unit leaders’ preferred time,
to review concerns and discuss barriers• Train-the-trainer model used for new staff
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Teamwork Training ProcessPhase IV: Comprehensive Evaluation
• Immediate feedback of training session• Change in Knowledge• Change in Attitude: Survey• Behavior Change: Observations• Process or Practice Changes• Impact on Clinical Outcomes
– Secondary measures
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Level 1 – Reaction: how did participants react to the training?
Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.
Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.
Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.
TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL
• Post-training reaction survey
• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.
• Observation of teamwork behaviors during routine patient care.
• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.
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Team Training Results: Will this training impact the way you do business?
5
35
60
0
10
20
30
40
50
60
70
80
90
100
NotSure
Prob.
%
Def.
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Team Training Results: Would you recommend this course to your co-workers?
100
0
10
20
30
40
50
60
70
80
90
100
NotSure
Prob.
%
Def.
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Level 1 – Reaction: how did participants react to the training?
Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.
Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.
Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.
TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL
• Post-training reaction survey
• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.
• Observation of teamwork behaviors during routine patient care.
• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.
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PICU Post-Training Survey Responses Summary. Question: “The physicians and nurses here work together as a well-coordinated team (Fisher Exact Test p value=0.011)”
86.9%
67.3%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Before (N=55) After (N=61)
% Agree slightly or strongly
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93.4%
75.4%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Before (N=57) After (N=61)
% Agree slightly or strongly
PICU Post-Training Survey Responses Summary. Question: “I know the proper channels to direct questions regarding patient safety in this clinical area (p value=0.007)”
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Level 1 – Reaction: how did participants react to the training?
Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.
Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.
Level 4 – Results: whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.
TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL
• Post-training reaction survey
• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.
• Observation of teamwork behaviors during routine patient care.
• Patient satisfaction survey.• Complication rate based on AHRQ PSI.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.
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Overall Teamwork in PICU (p value=0.0001, fisher’s exact test)
0.0%
27.8%
50.0%
22.2%
0.0%0.0% 0.0%
10.5%
52.6%
36.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Expected butnot observed
Observed butpoor
Observed butmarginal
Observed andacceptable
Observed andgood
% o
f to
tal e
ven
ts
Before (N=18)
After (N=19)
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Level 1 – Reaction: how did participants react to the training?
Level 2 – Learning: whether the training results in an increase in knowledge, skills or attitudes.
Level 3 – Behavior: whether participants change their behavior back in the workplace as a result of training.
Level 4 – Results: whether the training has affected process or outcomes, such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment.
TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL
• Post-training reaction survey
• Teamwork knowledge test.• Survey of attitude towards teamwork.• Survey of self-perceived communication skills.
• Observation of teamwork behaviors during routine patient care.
• Patient satisfaction survey.• Process or practice changes.• Length of hospital stay.• Adverse drug events.• Patients’ claims.• Staff satisfaction survey.• Nurse turnover rates.
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CT Patient in the OR
SBAR Report Attending
anesthesiologist to admitting nurse
“Rolling Call” Notification
Circulating nurse to unit clerk
Unit clerk notifies PCICU team
Direct Notification:
Charge NursePCICU Fellow
Batch Page:PCICU Attending
PCICU FellowNurse Practitioner
Respiratory TherapistCardiology Fellow
Primary nurse
Prepare for Patient Arrival at
BedsidePCICU team
Scripted template used in OR
Patient Stabilization Directed by
anesthesia & CT surgery teamsPatient
Transported to PCICU
Anesthesia & CT surgical teams
Admitting Nurse:
Performs brief ABC assessment
Secondary Nurse(s):
1. Places chest tubes to suction2. Obtains initial lab draw3. Documents
Respiratory Therapist:
1. Assumes airway mangement2. Places pulse oximetry & CO2 monitoring devices
Anesthesia: Transfer of physiological
monitoring to PCICU bedside system
Enter “Sterile Cockpit” *
Are all team members ready
for hand-off?
Scripted Report CT surgery
PCICU Providers:
Provides situational monitoring and
feedback
Scripted Report Anesthesia
Questions?Clarifications
Exit “Sterile Cockpit”Hand-off to PCICU team
complete
Cardiothoracic Surgical Hand-OffOperating Room to Pediatric Cardiac Intensive Care Unit (PCICU)
“Off Bypass” Notification
Circulating nurse to admitting nurse
* “Sterile Cockpit”
A safety concept borrowed from the aviation industry to ensure optimal focusby minimizing unnecessary distractionsduring critical processes
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Observations
OR – PICU Hand-Off Turnaround Time:
Before and After Intervention
0
5
10
15
20
25
30
35
40
45
50 Interventions
Tur
naro
und
Tim
e (m
inut
es)
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Operational Changes, Improvements in outcomes
• Time to critical labs drawn at hand-off• Briefings and debriefings implemented; SBAR
communication for nursing report, telephone communication
• Decrease in infection rates• Decrease LOS and increased throughput • Patient Satisfaction score exceeded target
(Press Ganey)• Work Culture survey score increased
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Implementing TeamSTEPPSacross Duke Medicine
• TeamSTEPPS has helped us overcome some initial barriers to team training
• 4 phase approach to be undertaken throughout high acuity areas at DUH, DRH and DRaH
• Training with specific tools and concepts (modules) in intermediate units and non-clinical areas
• Collaborative with UNC SoM, SoN– Assertion and speaking up
• TeamSTEPPS and simulation, virtual training