TeamSTEPPS and Reducing Patient Falls

1. TeamSTEPPS and Reducing Patient Falls Prepared for the RHQN December, 2013

2. Introduction • Jefferson Healthcare • 25 beds • CAH • Port Townsend, WA

3. Background • The Oregon Experience • ORHQN • Strategy for training • Implementation • Hard-wiring • Results?

4. What is TeamSTEPPS? Team Strategies and Tools to Enhance Performance and Patient Safety

6. Why use TeamSTEPPS? • Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes • Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error • Team skills are not innate; they must be trained AHRQ, 2012

7. Patient Falls • Falls account for nearly 40% of accidents in hospitals • Leading cause of injury and death among older adults • Root causes of falls in rural facilities • Not identifying patients at high risk for falls • Failure to implement safety strategies • Failure to routinely complete fall risk assessments • Failure to complete post fall assessment Ruddick, Hannah, & Schade, 2008

8. Team Events • Brief - planning • Huddle – problem solving • Debrief – process improvement

9. Leadership Skills Resource Management Delegation A strategy for balancing workload People, knowledge or information to complete a given task Goal is to prevent overload situations that compromise situation awareness Re-Distributing tasks or assignments Four steps: What to delegate To whom to delegate Communicateclear expectations Request feedback

10. Develop a Shared Mental Model SituationMonitoring(Individual Skill) SituationAwareness(Individual Outcome) Shared Mental Model(Team Outcome)

11. Situation Monitoring (Individual Skill) Situation Awareness (Individual Outcome) Staff need to: Be aware of what is going on Prioritize and focus on different elements Share this information with others The state of knowing the current conditions affecting the team’s work Knowing the status of a particular event/patient Knowing the status of the team’s patients Understanding the operational issues affecting the team Maintaining mindfulness “Teams that perform well hold shared mental models.” (Rouse, Cannon-Bowers, and Salas 1992)

12. Strategies to Increase Situation Awareness • Visual Cues • Posey System • Arm bands • Colored socks • Magnets on doors • Engage patients and family members • White boards in rooms • Patient Journals • Education • Hourly Rounding

13. Post Fall Huddle Debrief • Implement a post fall huddle or rapid response team • Interdisciplinary • Stabilize the patient • Process improvement • Debrief: Designed to improve outcomes • Use post fall assessment tool • An accurate reconstruction of key events • Analysis of why the event occurred • What should be done differently next time

14. Feedback • Implement a process for feedback • RCA • Debriefing • Incident reports • Quarterly newsletters • Staff Meetings • Leadership Briefings • Safety Rounds “Feedback is the giving, seeking, and receiving of performance-related information among the members of a team.” (Dickinson and McIntyre 1997)

15. Questions? Brandie Manuel, Director of Patient Safety & Quality Jefferson Healthcare Port Townsend, WA 98368 (360) 385-2200 ext. 2076 bmanuel@jeffersonhealthcare.org