s trategies and t ools to e nhance p erformance and p atient s afety owl # u:insv727

Strategies and Tools to Enhance Performance

and Patient Safety

OWL # U:INSV727

TEAMSTEPPS 05.2Mod 1 05.2 Mod 1 06.2 Page 2

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Objectives

Describe the TeamSTEPPS training initiative

Describe the impact of errors and why they occur

Describe the TeamSTEPPS framework

State the outcomes of the TeamSTEPPS framework


How we communicate and work together can make the difference between life and death. This video exemplifies this impact.

TeamSTEPPS is about reducing the likelihood of these stories recurring..

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Sue Sheridan

Sue Sheridan. 76 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.


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2006

Patient Safety and Quality

Improvement Act of 2005

Patient Safety Movement

Executive Memo from President

DoD MedTeams®

ED Study

Institute for Healthcare

Improvement 100K lives Campaign

“To Err is Human”

IOM Report TeamSTEPPS

1995 1999 2001 2003 2004 2005

JCAHO National Patient Safety Goals

Medical Team Training


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Indemnity Experienc e

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0

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Malpractice Claims, Suits, and Observations

Pre-Teamwork Training Post-Teamwork Training

Adverse Outcomes

50%Reduction

50%Reduction

(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN

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June July August Sept Oct Nov Dec Jan Feb M arch April M ay

Avg

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Sta

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ays)

Length of ICU Stay After Team Training OR Teamw ork Climate and P os toperative Seps is Rates (per 1000 discharges)

Group Mean

Low Teamwork Climate

Mid Teamwork Climate

High Teamwork Climate

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A HRQ National A verage

Teamwork Climate Based on Safety Attitudes Questionnaire

Low High(Sexton, 2006)Johns Hopkins

(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine


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Why TeamSTEPPS For Us?

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We know that communication is not straightforward. The following video clip exemplifies this reality.

What happened in this video?

It is a question of communication and assumptions.


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Another example of lack of communication resulting from assumptions is contained in this video.

We may chuckle at this honest miscommunication, but what can we do to make sure such a miscommunication does not happen while we are caring for our patients?

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Flowers. 8.7 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.


Let’s review our TeamSTEPPS tools and see how we can effect patient outcomes like other organizations who have improved patient outcomes.

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HuddleProblem solving Hold ad hoc, “touch-

base” meetings to regain situation awareness

Discuss critical issues and emerging events

Anticipate outcomes and likely contingencies

Assign resources Express concerns


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The second tool is CUS, an acronym that helps us remember three key signal words which include: concerned, uncomfortable and safety. Signal words, such as “danger,” “warning,” and “caution” are common in the medical arena. They catch the reader's attention. “CUS” and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue. This is a way of getting someone’s attention without yelling or using unprofessional language. It has the advantage of not alienating others and perhaps reducing the likelihood they will contact you the next time an emergency occurs.

First, state your Concern.Then state why you are Uncomfortable.If the conflict is not resolved, state that there is a Safety issue. Discuss in what way the concern is related to safety. If the safety issue is not acknowledged, a supervisor should be notified.

Regardless of which word is used, if we hear a someone use any CUS word, it is our cue to stop what we are doing and pay attention because patient safety is at risk.


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CUS


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Call-Out is…A strategy used to communicate important or critical information

It informs all team members simultaneously during emergency situations

It helps team members anticipate next steps

Important to direct responsibility to a specific individual responsible for carrying out the task

Avoid Thin Air Commands

…On your unit, what information

would you want called out?


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Read-Back is…

Closing the loop on information exchange!


Handoff

The transfer of information and authority/responsibility during transitions in care.

Includes SBAR information, giving an opportunity to ask questions, solicit a read-back/check back of information shared. Great opportunity for

quality and safety!


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SBARA technique for communicating critical information that requires immediate attention and action concerning a patient’s condition.

Situation – What is going on with the patient?

“I am calling about Mrs. L’s fetal heart rate tracing.

Background – What is the clinical background or context?

She is a primigravida who is being induced

Assessment – What do I think the problem is?

I think she is having late decelerations. I have stopped the Pitocin, and she is on her left side with oxygen on.

Recommendation – What would I do to correct it?

I am concerned. I would like you to come evaluate her tracing. When can I expect you?


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Vig3alg001parathyroidbad.mpeg : 26 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.


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How could this be prevented?

With better communication as shown inthe next video.


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parathyroidgood.mpeg : 53 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.


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How we communicate and work together can make a difference in the care of our patients.

Thank you for taking time to view this TeamSTEPPS presentation.

s trategies and t ools to e nhance p erformance and p atient s afety owl # u:insv727

Documents

t ools

human iom report t eam

insv727 slide

teamstepps framework

patient outcomes

teamstepps tools

teamstepps training

teamstepps framework