Implementing Team Training at Duke Karen Frush, BSN, MD Chief Patient Safety Officer Duke Medicine
Jan 14, 2016
Implementing Team Training at Duke
Karen Frush, BSN, MDChief Patient Safety Officer
Duke Medicine
THE JOURNEY
• PICU
• Peri-operative Services
• GSK Collaborative
• NCHA Collaborative
• Comprehensive Implementation across Duke Medicine
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
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
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
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
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
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
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.
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.
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.
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.
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
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)”
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.
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)
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.
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
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)
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
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