Implementing Team Training at Duke

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Implementing Team Training at Duke

• Karen Frush, BSN, MD
• Chief 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 units
  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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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

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.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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Team Training Results Will this training impact
the way you do business?

Not Sure
Prob.
Def.
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Team Training Results Would you recommend this
course to your co-workers?

Not Sure
Prob.
Def.
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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

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.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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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 value0.011)
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PICU Post-Training Survey Responses Summary.
Question I know the proper channels to direct
questions regarding patient safety in this
clinical area (p value0.007)

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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Complication rate based on AHRQ PSI.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

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.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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Overall Teamwork in PICU (p value0.0001,
fishers exact test)
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TEAM TRAINING EVALUATION BASED ON KIRKPATRICKS
FOUR-LEVEL EVALUATION MODEL

• Patient satisfaction survey.
• Process or practice changes.
• Length of hospital stay.
• Adverse drug events.
• Patients claims.
• Staff satisfaction survey.
• Nurse turnover rates.

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.
Level 3 Behavior whether participants change
their behavior back in the workplace as a result
of training.

• Observation of teamwork behaviors during routine
  patient care.

• Teamwork knowledge test.
• Survey of attitude towards teamwork.
• Survey of self-perceived communication skills.

Level 2 Learning whether the training results
in an increase in knowledge, skills or attitudes.
Level 1 Reaction how did participants react to
the training?

• Post-training reaction survey

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OR PICU Hand-Off Turnaround Time
Before and After Intervention
Turnaround Time (minutes)
Observations
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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