Craig Bunnell, MD, MPH, MBA Chief Medical Officer Dana-Farber Cancer Institute

1. Changing Culture for Good: Disseminating and Sustaining Team Training in Outpatient Oncology Across an Academic Medical Center and Community Satellites • Craig Bunnell, MD, MPH, MBA • Chief Medical Officer • Dana-Farber Cancer Institute • Boston, MA

2. Disclosure I have no conflicts of interest to declare.

3. DFCI Mission To provide expert, compassionate care to children and adults with cancer while advancing the understanding, diagnosis, treatment, cure, and prevention of cancer and related diseases.

4. Background • Multiple studies have found that 75% of errors occur because of deficiencies in communication and coordination of patient care. • Failures in coordination and communication have been associated with: • higher risk for error • increased mortality • longer hospital lengths of stay • higher staff turnover • Poor communication and misunderstandings contribute to a culture of blame, isolationism, and lack of trust.

5. Targets for Teamwork Background Joint Commission Sentinel Event Statistics

6. Background • The Institutes of Medicine and The Joint Commission have recommended implementation of team training techniques • Such techniques have been applied successfully in various “contained” inpatient settings (e.g. ICU, ER, OR, L&D, etc.) but never in an outpatient or oncology setting.

7. The Science of Teamwork • Based on 30 years of research (military, aviation, nuclear industries, more recently medicine) • Defines a team • Mitigates issues of hierarchy • Identifies necessary skills for optimum team performance • Relies on robust systems to support implementation of tools and agreements • Involves culture change

8. Team Training Concepts (Crew Resource Management) • Research for Army Aviation showed teamwork saved lives • 5 Principles of CRM • Asking for relevant information • Offering relevant information • Communicating and confirming proposed actions • Advocacy • Conflict resolution

9. Reduced Error Reduced risk of harm Decreased litigation exposure Double check Better systems Improved Efficiency Fewer errors Fewer pages Decreased wait times Fewer emails Improved Quality of Life Fewer distractions Less anxiety Skills for organization Improved Work Environment Improved Work Relationships Decreased finger pointing Decreased conflict Mutual trust What’s in it for us ? POTENTIAL BENEFITS Improved Patient Care

10. Why Team Training in Outpatient Oncology? • Chemotherapy process: most high risk/high volume activity in a cancer center (>150,000 infusion visits/yr) • Treatment regimens complex, involving multiple drugs; standard and investigational (342 clinical trials) • Treatment plans can be changed based on lab results • Clinical team often separated by geography, making direct communication challenging • Occurrence reports and ‘near miss’ data demonstrated opportunity to improve safety

11. The Intervention • Baseline data collection: staff surveys, safety reports • Engage Leadership: kickoff meeting • Observations, interviews with clinical staff • “Train the Trainer” session and determine “pain points” • Process Meetings: develop agreements, tools, system changes • Train ALL staff • “Go Live” • Post-data collection

12. Strategy for Change • Mandate from Executive Leadership and Board of Trustees • Clinical leaders teach and lead • Use performance data, actual ‘near-miss’ scenarios • “Train the Trainer” methodology • Project support: outside consultation, project manager • Continuous measurement and feedback • Refresher courses, trainings, video for new staff • Learning Collaborative: to sustain/spread best practices

13. Pediatric Oncology Benign Hematology (HSC) Neuro-Oncology (NOC) Hematologic Malignancies (HEO) Milford Regional Medical Center Breast Oncology (BOC) Institute Pilot Gynecologic Oncology (GYN) Dana Farber Cancer Institute - Team Training Dissemination: Initiation to Implementation Inpatient Londonderry Faulkner Hospital South Shore Hospital Sarcoma Oncology (SAC) Gastrointestinal Oncology (GCC) Head & Neck Oncology (HNO) Melanoma (MEL) Cutaneous Oncology (CUC) Planning Phase Genitourinary Oncology (GUC) Implementation Phase Thoracic Oncology (TOP)

14. Metrics • Patient arrival to infusion area with no chemotherapy orders • # of change orders not communicated • Staff perceptions of teamwork, communication, safety and respectful practice environment • Patient perception of teamwork (Press-Ganey) • Wasted drug related to communication failures within team

15. Breast Oncology: Post-Implementation Unlinked Appt. Availability of chemotherapy orders for unlinked visits increased from 70% to 97% and has been sustained

16. Breast Oncology: Reported Near Miss Events

17. Main Campus: Reported Near Miss Events

18. Patient’s Perception of Teamwork: Satellite vs. Main Campus

19. Staff Perception of Teamwork

20. Chemotherapy Order Intervention Data

21. Lessons Learned: Critical Strategies for Dissemination and Sustainability Support from Leadership: - Board of Trustee participation - Engagement of Executive Leadership - Early engagement of day-to-day leadership - Patient involvement Engage the Front-line in Development, Planning, Implementation - Train-the-trainer - Implementation--balance universal change with flexibility System/infrastructure redesign to support changes/agreements Execute, Measure and Refine - Metrics - Continuous feedback on team performance - Training plan for new employees - Periodic refresher course/iterative refinements - Acknowledge/Share Best Practices