A DoD Patient Safety Program with Validated Results

4. MEDTEAMS � A TEAM TRAINING ERROR REDUCTION SOLUTION Scientifically-based system grounded in two decades of aviation safety team training and appliedto fixed facility and combatcasualty healthcare setting An evidence based outcome focused solution: Performance improvement Error reduction Enhancing patient and provider satisfaction

5. BACKGROUND IN US ARMY AVIATION Revealed that Army aviation crew coordination failures from FY84-89 contributed to 147 aviation fatalities and cost more than $290 million. The vast majority of these mishaps involved highly experienced aviators who had demonstrated superior flight skills over hundreds or thousands of hours. Attributed failures largely to crew communication, workload management, and task prioritization errors. Commercial and transport aviation hadsimilar problems

6. SOLUTION AND PRACTICAL RESULTS Developed exportable aircrew coordination training and evaluation system Validated with 101st Aviation Brigade, Fort Campbell 20% + improvement in mission performance 40% + reduction in safety-related task errors Army estimated annual savings of 15 lives and nearly $30M and disseminated the program. Recent, real-world data showed savings to be closer to $60M per year.

7. EMERGENCY MEDICAL PARALLELS TO AVIATION �Pilot (provider) error� is an insufficient explanation for remedying errors. The model of blame and punishment does not provide long term solutions. Pilots (providers) operate within highly complex technical systems. Situations are presented wherein the time pressures and stakes are high. Situations are presented wherein the team leader (pilot or physician) must make decisions and take actions, but cannot be expected to have all the necessary information and cannot implement actions without assistance from team members.

9. NEEDS ASSESSMENT � CLOSED CASE SUMMARY

10. VALIDATION RESULTS Improvement in observable teamwork behaviors Reduction in observed clinical errors Reduction in risk management cases in the lead military ED Improvement in the quality of preparation for patients admitted through the ED Gain in the proportion of patients who report reduced pain at ED discharge Gain in the proportion of patients who report reduced sickness at ED discharge Increase in the number of patients who are highly satisfied with the care they received Reduction in daily variability of satisfaction reported by patients  Note: Patient volume increased 7-11% during the validation period

11. ADDITIONAL BENEFITS � BASED ON ANECDOTAL AND TREND DATA Savings associated with MedTeams implementation are conservatively estimated at between $4 and $10 per patient visit. Reduced costs associated with Sentinel Events and Risk Management cases Internal costs Loss of client base Reduction in staff turnover Estimates as high as 10% Cost to replace 1 nurse may be as high as $60,000 Improved patient satisfaction and community relations can increase census by 9% Improved execution of protocols Time to charcoal for poisoning Time to antibiotics for meningitis Decreased length of stay Decreased left without being seen and leaving against medical advice Improved staff morale � staff liked the MedTeams training and the MedTeams system Improved preparation for JCAHO assessment � MedTeams organizations tend to pass with flying colors Will help meet emerging HCFA and government goals to: Establish a patient safety program Meet federal goal of reducing mishaps by 50%

13. NMCP - MEDTEAMS HISTORY Began in old hospital ED - 1998 15 beds 150 patients per day Moved to new ED - April 1999 40 beds 225 - 300+ patients per day Huge paradigm shift

14. NMCP IMPLEMENTATION IN NEW ED Geographic Issues Large, sprawling ED Pediatric unit Fast Track Observation Unit Central work area Doctors� �Fishbowl� Separate Nurse/Corpsmen work area

15. NMCP IMPLEMENTATION Staff Issues 15 Attending Emergency Physicians 24 EM Residents variously rotating in Dept. Rotating interns, students 38 Nurses 60 Corpsmen Civilian contract providers Constant turnover of personnel is the norm

16. NMCP IMPLEMENTATION Program Issues Academic Model Staff teaching responsibility Resident graduate responsibility Divide acute patients among EM-1�s Business Issues Expeditiously process huge volumes of patients Bed crunches

17. NMCP INITIAL MEDTEAMS MODEL Main ED Only Bisect ED into �Green� and �Blue� Sides �Purple� Coordinating Team Scrub colors correspond to assigned teams Staff assignments to sides Physicians Nurses Corpsmen

18. NMCP INITIAL MEDTEAMS ACTIVITY Training Cadre of MedTeams instructors All new personnel undergo MedTeams training Continue to develop new instructors Leadership Unequivocal support of Department Chairman Designated Physician/Nurse/HM MedTeams Leaders

19. NMCP PROBLEMS WITH INITIAL PLAN Personnel turnover - need constant training Personnel numbers don�t match the plan Academic model supersedes MedTeams model Varying shifts preclude team meetings/briefs Geographic separation of physicians from rest of team Inconsistent buy-in by physicians

20. NMCP SOLUTIONS Concentrate on behavior principles Continuous training �MedTeams Resuscitation� drills Stress teamwork in all encounters Model teamwork at leadership level Integrated Management Team �All Team� Quarterly Meetings Facility revisions �Explode� Physician Fishbowl Divide work area by teams

21. NMCP CURRENT STATUS MedTeams is here to stay! Non-debatable Essential to running a large department Substantially improved communications among caregivers Enhanced mutual respect and camaraderie Continuous training integrated into department training cycle Shared sense of mission

22. NMCP: WHERE IS MEDTEAMS GOING? Slowly, but inexorably, becoming our culture as a Department Once we are fully a MedTeams culture, additional implementation steps become easier to accomplish Patient care and safety will continue to improve

23. Changed title from TCC for . . to DEPLOYMENT for . . . (RS, 11/2/99)Changed title from TCC for . . to DEPLOYMENT for . . . (RS, 11/2/99)

24. MEDTEAMS IN COMBAT CAREDEM/VAL Move to backup (RS, 11/2/99)Move to backup (RS, 11/2/99)

25. CC TCC FEATURES IMPLEMENTED WITH 28TH COMBAT SUPPORT HOSPITAL Applied validated MedTeams team dimensions and teamwork actions to 28th CSH�s training missions and conditions Provided teamwork training for all unit personnel Clinical and non-clinical Clinical and tactical situations Allowed for streamlined, training approach In Garrison: Three hour Just-in-Time Training In-Field: During training deployment Six edits--- (RS, 11/2/99) Added CC (casualty care) to title Global change to remove formal registration identifier from title Replaced ETCC team with validated MedTeams dimensions . . . Removed parenthesis from Just-in-Time Training Removed (FTX or real world) Changed Adaptive to . . . To Adaptable for . . .Six edits--- (RS, 11/2/99) Added CC (casualty care) to title Global change to remove formal registration identifier from title Replaced ETCC team with validated MedTeams dimensions . . . Removed parenthesis from Just-in-Time Training Removed (FTX or real world) Changed Adaptive to . . . To Adaptable for . . .

26. OUTCOMES OF CC TCC IN THE 28TH CSH Effective teams have and in future will . . . Improve quality, not just minimize errors Change from a clinical, task-oriented focus to a situationally aware team focus Emphasize team performance instead of individual performance Be proactive not reactive Manage workload Improve communication among team members Strive to improve teamwork behaviors and mission outcomes Enhance PROFIS integration Global edit to titleGlobal edit to title

27. CC TCC SUCCESS STORIES Two-Challenge Rule 7 days into the JRTC exercise, the EMT MD has been up for many hours. A soldier arrives with a complaint of an allergic reaction. The MD orders Benadryl 125mg IVP. Two 91Bs question the order as too high a dose. The MD restates the order for Benadryl 125mg IVP. The medics challenge again stating they have never given that high a dose. The MD recognizes the confusion of another drug [Solu-Medrol] and orders the correct dose of Benadryl 50mg IVP. Team Identification Red armbands are placed on the Team Coordinator (Head Nurse or Staff Physician) for each area within the CSH. During the AAR of a Mass Cal exercise, multiple areas identified the armbands as extremely helpful in coordinating assistance and passing critical information. Additionally, identified Triage Office with different armband during Mass Cal exercise. Team Structure Identifying team leaders for each TEMPER team and using the MedTeams teamwork concepts helped to get the hospital built in less time (from 3 days to 2 days). PROFIS integration improved with TEMPER teams as well as clinical areas Changed (by almost 1 day) to (from 3 to 2 days) (RS, 11/2/99)Changed (by almost 1 day) to (from 3 to 2 days) (RS, 11/2/99)

28. 28TH CSH�S EXPECTATIONSFOR CC TCC Commitment to change the TO&E culture to one that is Team focused, not individual or task focused Required training of all personnel (Medical and non-medical members) Reinforcement of MedTeams principles in work area both in deployed status and in garrison Recognition that significant change will require long-term leadership commitment and sustainment training Two edits--- (RS, 11/2/99) Changed . . . Not individual focused to . . . Not individual or task focused Changed Reinforcement of principles . . . To Reinforcement of MedTeams principles . . .Two edits--- (RS, 11/2/99) Changed . . . Not individual focused to . . . Not individual or task focused Changed Reinforcement of principles . . . To Reinforcement of MedTeams principles . . .

29. DEPLOYMENT TO 28TH CSH Identify and develop CC TCC Trainers from 28th CSH personnel Certify CC TCC Trainers by observing Instructor Course Integrate CC TCC into 28th CSH�s Training Calendar Ensure 100% CC TCC Training for SFOR-9 and SFOR-10

31. MAMC ED MEDTEAMS Initiated 1993 Alpha test site for MedTeams project 1995-1998 Sustainability following testing Every other month new/refresher course Costs include day of personnel loss every other month plus training new instructors in Boston Currently 7 instructors at MAMC Goal is to train instructors at MAMC to avoidtravel Error reduction sustained as measured by RM cases

32. WHY OBSTETRICS? DoD claims for OB/GYN $35 million paid in OB claims (AMEDD, 1998-2000) OB: 8% of total number of claims OB: 25% of total paid claims (1998-18%,1999-25%, 2000-34%) 3 of top 10 MHS-wide DRGs are OB: #1-Vaginal delivery (30,456) #2-Cesarean delivery (8,566) #10-Antepartum complications (1,929) Volume of patients demonstrates OB has the burden of inpatient disease in DoD

33. L&D SIMILARTIES TO EMERGENCY MEDICINE Communication and coordination between highly skilled and experienced personnel Physician error is an insufficient explanation for remedying errors Multiple urgent and non-urgent patient evaluations Emergent procedures coordinated with multiple staff members (physicians, nurses, anesthesia) Need for smooth and rapid triage and disposition of patients Operate within highly complex technical systems

34. L&D DIFFERENCES WITH EMERGENCY MEDICINE Episode of care is more than L&D visit (positive pregnancy test to delivery/postpartum) Multiple outpatient and inpatient visits occur before the final inpatient admission for delivery Outpatient obstetric record is critical to the inpatient decision making process, care and outcome Staffing patterns and physician-patient relationship Errors during the outpatient visits directly affect outcomes from the L&D admission

35. MEDTEAMS APPLICATIONS IN OBSTETRICS AND GYNECOLOGY Cross-validation to obstetric care Review antepartum, intrapartum and postpartum care Needs assessment Labor and delivery Review of closed claims, risk management and PCE cases

36. INITIAL NEEDS ASSESSMENT IN L&D 60% of closed cases had a significant teamwork failure in L&D Most frequent errors included failure to: Identify and establish protocol to be used or develop a plan Provide situation awareness updates Communicate decisions and actions to team Execute protocol or team-established plan

37. MEDTEAMS FOR OBSTETRICS Develop cohort and experimental design Develop training and evaluation for OB Execute national validation test-bed Enhance MedTeams program in OB/GYN through additional research efforts. For example Evaluate the effect of electronic obstetric record use to augment MedTeams. Assess its impact on integration, communication, and outcomes. Evaluate the use of patient simulators to augment MedTeams training

39. CONGRESSIONAL AND DOD ACTIONS FY01 Defense Authorization Bill Establish two Centers of Excellence Deploy to 10 organizations per year Expand to other medical specialties Continue R&D program Transfer MedTeams R&D contract from ARL to AFIP at request of Health Affairs Presentation to DoD Patient Safety Working Group Other briefings provided upon request, e.g., BUMED, JSSB, TRICARE, QUIC Testimony

40. UNDER THE RADAR SCREEN R&D program remains active moving to L&D, other specialties, simulation, and ALS protocols. Center of Excellence being developed with goals and objectives. MAMC - University of Florida - Rhode Island Hospital Supported by DRC Currently being deployed to Bosnia with the 28th CSH; sustained with the 86th CSH; renewed interest expressed at the 47th CSH Six sustaining MedTeams EDs Madigan, Darnall, Eisenhower NMC-Portsmouth, NMC-San Diego 60th Medical Dental Group, Travis AFB

41. WHAT IS THE O&M FUTURE FOR MEDTEAMS An evidence-based discussion needs to proceed Decide among alternatives MedTeams costs and benefits Annual costs per Service approximately $250K depending on level of organic support Per seat cost of approximately $70 ($135) for year one and $30 ($55) for annual sustainment Benefit estimated at $4 to $10 per ED patient visit Similar savings expected in additional specialties Are we willing to develop a winning combination of DoD organic capability coupled with an appropriate level of contractor support?

45. KEY POINTS OF DoD AVIATION TEAMWORK TRAINING PROGRAMS Except for the Army, which is facing a costly re-invention of their ACT program, the other services have: Well staffed and funded ACT/CRM programs Flag officer influence in their ACT/CRM programs Full time program managers ACT/CRM training is an annual requirement - failure to train is cause to ground an aircrew member ACT/CRM training continues throughout an aircrew member�s career ACT/CRM skills are integrated into daily operations ACT/CRM performance is used to evaluate aircrew members ACT/CRM training is performance and mission based ACT/CRM training is aircraft and mission specific There is ongoing R&D related to ACT/CRM issues

46. A COMPARISON OF MEDTEAMS AND MTM USING EMPIRICALLY VALIDATED PRINCIPLES OF EFFECTIVE CRM TRAINING AND GUIDANCE FOR TRAINING DEVELOPERS1

47. A COMPARISON OF MEDTEAMS AND MTM USING EMPIRICALLY VALIDATED PRINCIPLES OF EFFECTIVE CRM TRAINING AND GUIDANCE FOR TRAINING DEVELOPERS1 (Continued)