David Grant USAF Medical Center

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David Grant USAF Medical Center

• Simulation Team Skills or Individual Skills
• Mr. Michael McCann, MA, MBA
• Mr. Eugene Bryan, BS

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Imperative For Change

• 2002-2005 Serious Adverse Events
• Seven Sentinel Events
• 3 Deaths
• Fire in OR led to facial disfigurement
• O2 Cylinder in MRI - 50,000 damages
• Improper cleaning of Sigmoid scopes potential
  infection of 26 patients
• Wrong site Ophthalmology laser eye surgery
• All Events had lapses in communication and
  teamwork
• RCA identified exceptionally well-trained nursing
  staff in the ICU, as well as skilled attending
  physicians/surgeons.
• 17 investigative statements indicating a
  frustration with the lack of communication as a
  team
• Incident Reports identifying poor communication
  skills / tools

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Institute of Medicine ReportTo Err Is Human

• Impact of Error
• 44,00098,000 annual deaths occur as a result of
  errors
• Medical errors are the leading cause, followed by
  surgical mistakes and complications
• More Americans die from medical errors than from
  breast cancer, AIDS, or car accidents
• 7 of hospital patients experience a serious
  medication error

Cost associated with medical errors is 829
billion annually.
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Joint Commission Sentinel Event Root-Causes
A Time For Change
Nationally reported data (TJC Sentinel Event
Database) communication issues cited as a
root-cause in 65 of reviewable sentinel events
in 2006
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Why Do Errors OccurSome Obstacles
A Call For Teamwork

• Workload fluctuations
• Interruptions
• Fatigue
• Multi-tasking
• Failure to follow up
• Poor handoffs
• Ineffective communication
• Not following protocol

• Excessive professional courtesy
• Halo effect
• Passenger syndrome
• Hidden agenda
• Complacency
• High-risk phase
• Strength of an idea
• Task (target) fixation

The expectation is not for healthcare providers
to be perfect but that healthcare teams are
perfect
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Simulation and Patient Safety

• Josie King
• Jessica Santorum
• Sue Sheridan
• Paul McCann

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Building Simulation Around Teams
Team Strategies Tools to Enhance Performance
Patient Safety

• Initiative based on evidence derived from team
  performanceleveraging more than 25 years of
  research in military, aviation, nuclear power,
  business and industryto acquire team
  competencies

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Outcomes of Team Competencies
The TeamSTEPPS Model

• Knowledge
• Shared Mental Model
• Attitudes
• Mutual Trust
• Team Orientation
• Performance
• Adaptability
• Accuracy
• Productivity
• Efficiency
• Safety

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Leadership

• Directive Leadership
• Briefs/Huddles planning or problem solving
• Debriefs process improvement

Leaders are responsible to assemble the team and
facilitate team events
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Situation Monitoring

• Keep patient/family members engaged
• Cross-Monitoring (watching each others back

• STEP
• IM SAFE

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Mutual Support

• Task Assistance
• Feedback
• Advocacy Assertion
• Two-Challenge (CUS)
• DESC Script

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Communication

• SBAR (Situation, Background, Assessment,
  Recommendation)
• Check-Back
• Call-Out
• Hand-Offs

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Leadership Commitment Support

• Strategic Initiatives
• Strategic Objectives
• Measureable Reportable
• Financial Commitment
• Personnel Equipment
• Executive Oversight

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Executive Commitment
Goal 90
June 07 Added TeamSTEPPS to Hospital Orientation
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Leadership Accountability
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Team Observation Scores

• Team Observation Tool 6 Criteria
• Teams Structure
• Leadership
• Situation Monitoring
• Mutual Support
• Communication
• Skills Observation

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Team Observation Scores
lt75 Red, 75-100 Yellow, 101-125 Green
These scores represent the average of all Tier 3
training conducted during each month.
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Team Observation Scores
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Simulations Tied Into Patient Safety Incidents

• High-Risk/Low Volume Cases
• Incident reports that identify potential areas of
  risk
• Breakdown in communication
• Patient care is not delivered outside team
  environment

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Incorporating TeamSTEPPS SkillsIn Clinical
Simulations

• Curriculum Development
• Teaching vs Correction
• Identifying Staff Deficiencies
• Identifying Organizational Weaknesses

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Curriculum Development

• Should be developed in support of corporate
  strategic goals
• Patient safety curriculum development
• High risk/low volume
• Patient incidents
• All curriculum should have a team approach
• Incorporate roles in scenarios that include team
  participation
• Debriefs and Evaluations should be included in
  training