Katherine Jones, PT, PhD Wendi Nordhausen, RN, BSN Mark Goodridge, RT (R) (CT)

1. The University of Nebraska Medical CenterAHRQ Annual Meeting Sept. 15, 2009Measuring Improvement in Hospital Teamwork: Diffusion of TeamSTEPPS in Critical Access Hospitals Katherine Jones, PT, PhD Wendi Nordhausen, RN, BSN Mark Goodridge, RT (R) (CT) PHOTO GOES HERE (Need higher resolution

2. Our Team Anne Skinner, RHIA Robin High, MS, MBA Andrea Bowen, BA 99 Master Trainers from 24 Critical Access Hospitals Our Funding AHRQ Office of Communications and Knowledge Transfer Nebraska Dept of Health and Human Services Good Samaritan Health Systems Network St. Elizabeth CAH Link Direct funds from 14 Critical Access Hospitals Medicare Rural Hospital Flexibility Program (Flex Program) Acknowledgements 2

3. Objectives • Describe a collaborative approach to implementing TeamSTEPPS within a state/region • Use the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) to plan and evaluate the implementation of TeamSTEPPS • Use ‘Diffusion of Innovations,’ Kirkpatrick’s Taxonomy, and decision frame to explain variations in success implementing TeamSTEPPS • Implement lessons learned from two Critical Access Hospitals to facilitate adoption of TeamSTEPPS

4. TeamSTEPPS Background • 05 – 07 AHRQ Partnerships in Implementing Patient Safety Grant (1 U18 HS015822) • Purpose: Implement patient safety practices of voluntary medication error reporting and organizational learning in 24 CAHs • Aim: Develop organizational infrastructure for reporting and analyzing medication errors needed to identify system sources of error • Evaluate impact of this infrastructure change on safety culture with HSOPS • HSOPS results revealed need for teamwork

5. Implementation Background • 3/2008 initial funding through AHRQ Office of Communications and Knowledge Transfer • Purpose: Implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals • Aim: Evaluate impact of TeamSTEPPS training program on safety culture using our rural-adapted version of the AHRQ HSOPS • Collaborative funding through 12/2010

6. Collaborative Funding

7. Implementation Cycle Cycle I 2007 – 2009 24 CAHs Cycle II 2009 – 2010 15 CAHs

8. Diffusion of TeamSTEPPS in Nebraska NE TeamSTEPPS 35/65 CAHs, 1 Network Hospital, 3 IA CAHs, 1 LA CAH

9. Measuring to Implement TeamSTEPPS TeamSTEPPS Tools to bridge gap between belief and behavior. • Situation Monitoring • Mutual Support… Seeking and offering Task Assistance • Briefs, Huddles, Debriefs

10. Measuring to Implement TeamSTEPPS TeamSTEPPS Tools to bridge gap between belief and behavior. • Advocacy and assertion • I’m Concerned, I’m Uncomfortable, Stop the procedure (CUS)

11. Measuring to Implement TeamSTEPPS TeamSTEPPS Tools to improve structured communication across shifts and departments. • SBAR, Closed loop communication, Seeking Clarification • Huddles and WalkRounds after shift change • I PASS the BATON

12. Measuring to Evaluate TeamSTEPPS Team Behaviors Added to HSOPS • Use SBARw/in dept • Offer task assistance w/in dept • Use structured communication (SBAR, I PASS the BATON) across depts • Conduct a huddle in response to changing workloads • Conduct a debrief for improvement when things don’t go according to plan Responses • Never • Rarely • Sometimes • Most of the Time • Always

13. Evaluation: Adoption of Behavior

14. Implementing TeamSTEPPS atClarinda Regional Health CenterClarinda, IowaMark Goodridge, RT (R) (CT)

15. TeamSTEPPS at Clarinda Regional Health Center • Critical Access Hospital – 25 Beds • Average daily census 7- 8 • Census can vary from 4 -14 in 24 hours • 85% of services are out-patient • 400-500 ED visits per month • 600-700 specialty clinic visits per month • 225 employees – FT & PT Page County Iowa Pop. 15,664 Density 32/sq mi

16. TeamSTEPPS Training—Master Trainers • 3 Master Trainers trained April 2008 with UNMC Collaborative • Senior Staff member • Elaine Otte COO • Frontline staff • Mark Goodridge RT (R) (CT) • Jennifer Chambers RN (ED)

17. TeamSTEPPS Training—Leadership Leadership Development Training • Department managers • Senior Staff members • Board of Trustees • Fundamentals Course • One time training session off campus • Managers required to submit action plans to COO Role Play during Leadership Development

18. TeamSTEPPS Training—All Staff • Nov & Dec 2008 • 15 – 20 staff per class • All classes interdisciplinary • Essentials course • Team building exercises • Goal to train all staff within 2 weeks by Master Trainers & Education Director Team Building Exercise during Staff Training

19. We Defined TeamSTEPPS as a Change • We created a Sense of Urgency • Results from the 2006 Patient Safety Survey • Sue Sheridan video • We ensured staff viewed TeamSTEPPS as consistent with our mission to provide exceptional care in a safe environment • TeamSTEPPS is better than our “old way of communicating” • Shared stories of impact of our “old way” • TeamSTEPPS videos and role playing

20. We Obtained Management Support • Senior leaders are educated and supportive of the TeamSTEPPS initiative • COO trained as Master Trainer • The board is educated and supportive of the TeamSTEPPS initiative • Included in the Leadership Fundamentals Training Session • Medical Staff education—in progress; goal is to shift from “I” to “We”

21. Our Champions Led the Way • Mark (Radiology) & Jennifer (Nursing)- front line champions • Led the organization by training staff & mentoring department managers • Use TeamSTEPPS language • Overcome resistance by engaging key employees and managers

22. Resources Used for Implementation • UNMC’s support • conference calls • sharing tools • Lessons Learned Conference Nov 2008 • Senior Staff support • Funds allocated for the program by COO Our Poster at UNMC Lessons Learned Conf Nov. 2008

23. We are Sustaining TeamSTEPPS • “Not a flavor of the month” • Senior Staff and Board of Trustees buy-in • Use TeamSTEPPS tools and language—role models • Focus on Debriefs for drills and code alerts • Part of new employee orientation • COO introduces concept to all new employees • Biannual Essentials Course • All receive a pocket guide

24. Lessons Learned and Next Steps • Support of Board of Trustees • Attended Leadership training • Next Steps • Medical Staff training • Sustainment – Use TeamSTEPPS tools in specific areas • Communicate use of TeamSTEPPS by professional organizations (AORN)

25. We are Measuring to Identify Improvement • How do we know our training program resulted in change in culture, learning and behavior? • Data from HSOPS • Observed Changes in process and behavior

26. Implementing TeamSTEPPS atChase County Community HospitalImperial, NebraskaWendi Nordhausen, RN, BSN

27. TeamSTEPPS at Chase County Community Hospital • 25 Bed – Critical Access Hospital • Average Daily Census – 2 to 6 patients • Staff 105 employees • Attached clinic • 3 physicians, 2 physician assistants, 2 nurse practitioners Chase County Pop. 3,269 Density 4/sq mi

28. TeamSTEPPS Training • 4 Master Trainers - April 23 - 25th, 2008 as part of UNMC Collaborative • Included ALL staff and medical staff • Board informed • Included all modules in Fundamentals Course– adapted to our specific needs • Offered 4 to 5 times each week in 60 – 90 minute sessions for 7 weeks • Included one 6 hour make-up day

29. We Defined TeamSTEPPS as a Change • We created a sense of urgency… • We ensured staff viewed TeamSTEPPS as consistent with our mission and vision • We ensured staff saw TeamSTEPPS as better than our “old way of communicating” • Started with SBAR and trauma debriefs

30. We Obtained Management Support Senior leaders are educated and supportive of the TeamSTEPPS initiative The board is educated and supportive of the TeamSTEPPS initiative Medical Staff is educated and supportive of the TeamSTEPPS initiative

31. Our Champions Led the Way CEO – Master Trainer, Leader Physician - QI background Linda (Resp. Therapist), Lori (Lab Coord.), Wendi (QI Coordinator) – Interdisciplinary Master Trainers

32. We are Sustaining TeamSTEPPS • Employees know TeamSTEPPS is a priority • Use the tools and language • Scenarios brought to manager & dept meetings • TeamSTEPPS changed day to day processes • SBAR • Trauma Debriefs • Our organization supports and rewards involvement in TeamSTEPPS

33. Resources Used for Implementation • UNMC conference calls • Administrative Support • Lessons Learned Conference • Critical Access Hospital Network Meeting • Additional Master Trainers could make a difference Our Poster at UNMC Lessons Learned Conf Nov. 2008

34. Lessons Learned and Next Steps Most effective aspect of implementation- trained all staff in Fundamentals Least effective aspect…change team function Current and Future Focus – Orient new employees, Quarterly refresher courses, higher level of implementation and integration of the tools.

35. We are Measuring to Identify Improvement • How do we know our training program resulted in change in culture, learning and behavior? • Data from HSOPS • Observed Changes in process and behavior… mails structured by SBAR, conversations about “processes” and communication

36. Measuring to Evaluate for IndividualHospitals and the CollaborativeKatherine Jones, PT, PhD

37. Measuring to Evaluate Kirkpatrick’s Taxonomy of Training Criteria Alliger et al. A meta-analysis of the relations among training criteria. Personnel Psychology. 2006, 50: 341-358.

38. Rural HSOPS Spring 2009 • Population Surveyed • 24 Hospitals evaluate impact of TeamSTEPPS Implementation 2008 – 2009 (2,137 respondents) • 13 Hospitals obtain baseline prior to TeamSTEPPS Implementation (1,328 respondents) • Added Teamwork Related Items to HSOPS • Overall Response Rate for 37 Hospitals 3465/4601 = 75.3% • Range 51% - 96%

39. Added HSOPS Knowledge & Behavior Items Knowledge • Teamwork experience • Define brief • Define SBAR • Define CUS • Apply CUS Behavior • Use SBARw/in dept • Offer task assistance w/in dept • Use structured communication (SBAR, I PASS the BATON) across depts. • Conduct a huddle in response to changing workloads • Conduct a debrief for improvement when things don’t go according to plan

43. BELIEF Huddle Task Assist BELIEF Advocate 2 Challenge CUS

45. Decision Frame Revealed in HSOPS • Decision frame: mental structures people use to organize the world • Reference point changes with knowledge • If behaviors change to reflect change in knowledge… Belief may not change • Consider item level scores not just dimension scores to track change over time • If behavior not consistent with new knowledge…HSOPS results less positive after training • Seek higher standard based on new knowledge Tversky A, Kahneman D. Science. 1981;211:453-458. Wright G. Goodwin, P. Strategic Management Journal, Strat Mgmmt J. 2002;23:1059-1067.

46. Change In Frame? Debriefs

48. Evaluation: Training - Knowledge

49. Evaluation: Knowledge - Behavior