Introduction to Team Training

1
Introduction to Team Training

• Colorado Patient Safety Coalition
• Carol Anne Tarrant, RN, MS, JD
• Jeffrey L. Varnell, MD, FACS

2
Agenda

• Are we doing as well as we can?
• Whats preventing us from doing better?
• Are there any models that we can incorporate?
• What skills tools can we learn?
• Is there any evidence that all this will make a
  difference?

3
An OverviewAviation Healthcare
4
Aviation Healthcare Both Have Preventable
Errors
5
Healthcare Statistics Regarding Preventable
Errors

• Healthcare research shows 70 of adverse events
  were preventable
• One study shows 54 of surgical errors are
  preventable
• Preventable errors cost 17 billion (IOM)
  ANNUALLY!
• 70-80 medical mishaps are caused by human
  factors issues related to interpersonal
  interaction

6
A Human Factors Expert Looks at
Healthcare

• No one in charge
• Safety is not a corporate priority
• Failure to observe basic safety practices
• Tolerance of unsafe practices
• No systematic data collection
• No analytic response to accidents
• Reliance on training punishment
• No training in safety, teamwork

7
Current Healthcare Mental Models

• Hierarchy
• One person responsible for knowing everything
• Machismo
• We can perform at maximum efficiency as long as
  needed
• Personal blame
• If something goes wrong, someone is to blame
• Speed is supreme
• Turnover time, etc.
• Dictatorial communication
• I only have to say this once!
• If I speak up, I will be mocked or belittled!
• Task compartmentalization
• Dont tell me what to do!
• Im only responsible for my area!

8
Case History

• 540 am - Pt. at 37 wks. gestation arrives at
  hospital with history of heavy bleeding
• 600 am - Attending notified, requests deck doc
  to evaluate
• Deck doc orders US no sign of abruption, pt.
  still bleeding. Waits for attending to arrive.
• 700 am Attending arrives. Dx abruption.
• 736 am - C/S accomplished.
• APGARs 1,1,1 infant survives with severe
  neurological impairment.

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Our Conversation

• Why communication is the heart of the matter
• The limits of human performance
• Lessons from high reliability units
• Human Factors Skills
• Briefings Time outs, pauses
• Assertion Its a hierarchical world!
• Situational Awareness
• Debriefing

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Why Communication

• The overwhelming majority of untoward events
  involve communication failure
• Somebody knows theres a problem but cant get
  everyone in the same movie
• The clinical environment has evolved beyond the
  limitations of individual human performance

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What Happens Without Communication
12
NASA Simulator Study

• One of the key differences between high
  performing crews low performing crews the
  high performers talked more.
• One characteristic of ineffective teams is that
  when a problem arose, they simply stopped talking
  communicated less.

13
JCAHO Sentinel Events

• Communication breakdowns remain the primary root
  cause of more than 60 of the 2034 sentinel
  events analyzed.
• The majority of sentinel events (75) resulted in
  a patient death.

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Error is Inevitable Because of Human Limitations

• Limited memory capacity 5 pieces of information
  in short term memory
• Negative effects of stress error rates
• Tunnel vision
• Negative influence of fatigue other
  physiological factors
• Limited ability to multitask cell phones
  driving
• Flawed judgment

16
Our Error Model Today

• Trained to be perfect - knowledge competence
  are equated with the absence of error
• Healthcare culture rewards perfection frowns
  upon error
• Individual agency - fix the person the problem
  goes away

17
Captain of the Ship vs. Team Leader

• Knows everything
• Remembers everything
• Is responsible for everything
• Always does things my way

• Values relies on input from other team members
• Recognizes limitations of workload, fatigue,
  stress, etc.
• Makes decisions based on all sources of info
• Sees value in consistent processes

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Reoccurring Organizational Systems Problems

• Communication
• Shift reports, sign outs hand-offs
• Inadequate, inaccurate information
• Task fixation, task overload
• Assertion, escalation of communication
• Supervision, leadership

MMI Company data of 250 hospitals over 10 years
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Where Do Things Fall Through the
Cracks ?

• Systems information, tests, diagnoses
• Communication
• Hand-offs
• Failure of recognition
• Failure to rescue

21
Errors in Anesthesia

• Human error accounts for 80
• Failure to perform normal check
• Lack of proficiency with equipment
• Lack of vigilance, distraction
• Haste
• Lack of experience with technique

Cooper et al, Anesthesiology, 1984.
22
JCAHO Patient Safety Goals

• Read-backs on verbal telephone orders / test
  results
• Identify patient from 2 sources
• Verification of correct patient, correct site,
  correct procedure
• Briefings before procedures, operations
• Infusion pumps / monitor alarms
• Nosocomial infections
• Medication reconciliation / communication
• Actions to prevent risk of falls

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Avoidance of Wrong Site Surgery JCAHO Standards

• Patient to mark side of surgery
• Visit with patient pre-op pre-anesthesia -
  sign your site
• Confirm with other information - e.g consent
  form
• Time out in OR to confirm correct patient,
  correct surgery, correct side or level

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COPIC Wrong Site Surgery Statistics 2000-2004
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First the Problem Now the Solution!
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Lessons from Aviation Crew Resource Management

• Focus on teamwork,communication, flattening
  hierarchy, managing error, situational awareness,
  decision making
• Non-punitive reporting of near misses, 500,000
  reports over 15 years
• Very open culture with regard to error safety

27
Team Training The Process

• Needs assessment
• Measure of culture safety attitude
  questionnaires (SAQs)
• Training sessions multidisciplinary,
  interactive
• Observation coaching onsite
• Follow up training sessions
• Development of protocols drills, debriefing
  sessions, simulations
• Follow up questionnaires (SAQs)

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Team Approaches to Errors

• Culture
• Communication Skills
• SOAP for communication
• Briefing debriefing
• Assertiveness skills
• Checklists
• Read-back
• Call out
• Outcomes Errors, costs, turnover rates,
  satisfaction rates

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Communication Skills

• S Situation
• O Objective findings
• A Assessment
• P Plan for action recommendations

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Briefings Key Elements Checklist

• Got the persons attention
• Made eye contact, faced the person
• Introduced self
• Used persons name familiarity is key !
• Asked knowable information
• Explicitly asked for input
• Provided information
• Talked about next steps
• Encouraged ongoing monitoring cross-checking

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Debriefing

• An opportunity for individual, team
  organizational learning
• The more specific, the better
• What did we do well?
• What did we learn?
• What would we do differently next time ?
• Who is accountable to making sure any changes are
  made?

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Helpful Hints on Assertion

• Focus on the common goal quality care, the
  welfare of the patient, safety its hard to
  disagree with safe, quality care
• Avoid the issue of whos right whos wrong
  concentrate on doing the right thing
• De-personalize the conversation
• Actively avoid being perceived as judgmental
• Be hard on the problem, not on the people
• Implement critical language CUS

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When Assertion is Difficult
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Situational Awareness

• The extent to which Team Members are aware of the
  status of a particular clinical event, patient
  status, or operational issues pertaining to the
  teams overall tasks goal.

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Red Flags
Loss of Situational Awareness

• Ambiguity
• Reduced/poor communication
• Confusion
• Trying something new under pressure
• Deviating from established norms
• Verbal violence
• Doesnt feel right
• Fixation
• Boredom
• Task saturation
• Being rushed / behind schedule

36
Expert Decision Making

• Expert pattern matching against large mental
  library, quick, accurate if confirm correct
  answer
• Novice library is empty slow, error prone
  process
• Certain diagnoses are favored- frequent, recent,
  serious
• Trial error/personal experience

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Human Factors

• Briefings
• Appropriate assertion
• Situational awareness
• Debriefing
• Common mental model

38
Case History

• 540 am - Pt. at 37 wks. gestation arrives at
  hospital with history of heavy bleeding
• 600 am - Attending notified, requests deck doc
  to evaluate
• Deck doc orders US no sign of abruption, pt.
  still bleeding. Waits for attending to arrive.
• 700 am Attending arrives. Dx abruption.
• 736 am - C/S accomplished.
• APGARs 1,1,1 infant survives with severe
  neurological impairment.

39
Communication Skills

• S Situation
• O Objective findings
• A Assessment
• P Plan for action recommendations

40
Characteristics of
High Reliability Units

• Preoccupation with failure
• Refusal to simplify
• Commitment to resilience
• Deference to expertise
• Sensitivity to operations

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Plan for Action High Reliability Units

• Policy protocol development
• Safety attitude surveys
• Teamwork training follow-up
• Regular interdisciplinary debriefings/reviews
• Review of operative injuries
• Simulator training on known hazards
• Patient safety position

42
Measuring Success

• Patient injuries
• Team satisfaction
• Patient satisfaction
• Nurse / staff turnover
• Lawsuits claims

43
Thank You!

• Questions???