Team Training – TeamSTEPPS® 2.0 Improves an Already Proven Program
By Stephen M. Powell, MS
Recently, the Agency for Healthcare Research and Quality (AHRQ) announced the release of an updated version of the successful teamwork and communication curricula TeamSTEPPS 2.0—Strategies and Tools to Enhance Performance and Patient Safety. This latest update to the curricula incorporates new research and lessons learned from the past 10 years of medical teamwork and communication training. Those who are familiar with the curricula will still find the core learning materials focused on team structure, communication, team leadership, situation monitoring, and mutual support. Version 2.0 enhances a program that is already successful, as evidenced by the increasing number of PubMed citations in the team training research and practice. Before the TeamSTEPPS launch in 2005, approximately 90 team training citations were recorded compared to over 670 citations since then (Weaver, et al., 2014).
This new evidence has been incorporated into 2.0, while redundant content has been eliminated to streamline course delivery. Additional implementation modules include coaching, action planning, and change management (yes, the penguins from the popular Our Iceberg is Melting survived*). A new Measurement module has been added to support enhanced evaluation strategies. The new Course Management Guide provides detailed guidance for selecting and customizing your TeamSTEPPS training events based on the audience: trainer, coach, clinical, and non-clinical. Helpful tips are shared about selecting instructors and coaches to help rollout the initiative. AHRQ offers new web-based and blended TeamSTEPPS training opportunities, while traditional classroom experiences are available through government, non-profit agencies, and private improvement vendors. Recommendations for integrating TeamSTEPPS practices into simulation and other performance improvement initiatives aimed at improving patient and staff satisfaction are included.
How to Leverage the Power of TeamSTEPPS
So, how can this proven set of teamwork tools, strategies and communication practices be further leveraged and integrated throughout your organization to create safer, more patient-centric systems of care?
As a consultant, I have worked with over 500 organizations worldwide improving team performance and have found TeamSTEPPS to be a valuable and versatile set of tools for achieving a wide array of quality improvement goals. Since TeamSTEPPS is focused on human performance improvement, we have found that the SEIPS (Systems Engineering Initiative for Patient Safety) model for safer system design is a reliable way for integrating TeamSTEPPS into almost any improvement initiative aimed at creating safer systems (Carayon, et al., 2006). The SEIPS model, also originally funded by AHRQ, has been successfully applied across work areas by multiple stakeholders.
This human factors-based approach places the person at the center of the (re)design process, which includes healthcare professionals and patients and their family members, all interacting within the safe system design process, which SEIPS breaks down into four elements: Organization, Technology/Tools, Tasks, and Environment. The Organization (culture, relationships, communication, leadership) element is where TeamSTEPPS fits best in the model and clearly interacts with Technology (electronic medical records, computerized provider order entry, incident reporting systems), Tasks (job content, demands, and controls), and the Environment (physical layout, noise, and design). Failing to assess all elements when creating a “bundled” practice may create latent threats to system reliability. If you have focused your TeamSTEPPS intervention exclusively on the person through team training events, you haven’t fully leveraged the power of integrating with other safe system design elements that could be impacting your desired safety processes and quality outcomes. Let’s look at some specific role-based applications and experiences integrating improvement resources in a hospital environment (although systems thinking should also include ambulatory settings).
A hospital CEO may choose a comprehensive improvement framework like the SEIPS model to improve system reliability across the board—developing what is known as the High Reliability Organization (Chassin, 2013). Although the Board and senior leadership may be responsible for all five parts of the improvement system, accountability is dispersed to departments, units, and patient care teams through mid-level and frontline leaders. In some organizations, quality management professionals coordinate continuous system improvement in conjunction with risk management, patient safety, M&M committee, patient relations, and human resources. This cross-department coordination for improvement requires significant trust, transparency, and mutual respect—all targeted outcomes of TeamSTEPPS. Senior leaders may choose to deploy targeted TeamSTEPPS principles like feedback, closed-loop communication, and conflict management tools among the quality management team to improve their team functioning. Those who are familiar with TeamSTEPPS recall that the only knowledge outcome from the curricula is a shared mental model—being “on the same page.” That may sound simple, but it may be difficult to achieve due to common barriers such as limited time, competing agendas, production pressures, and traditional hierarchies/silos. If I am the quality manager, TeamSTEPPS helps me team across departments, disciplines, and domains more effectively by using a common language.
Hospital Engagement Networks
We have worked closely with many of the Hospital Engagement Networks (HENs) as part of the CMS Partnership for Patients (PfP) program over the past three years, integrating TeamSTEPPS practices into this important quality improvement effort. Working with the Joint Commission Resources HEN, we created a comprehensive set of leadership practices for executive leaders and physician champions to promote patient safety and quality by including TeamSTEPPS in the Organization suite of tools (Jayanthi, 2014). Additionally, executives need proven methods such as a culture of safety and patient-centered care practices to support organizational health. Knowing where and how these interdependent initiatives intersect reduces the complexity of improvement and optimizes improvement resources.
Clinical performance improvement (PI) coordinators are responsible for engaging clinical leaders in the adoption of evidence-based practice bundles or processes of care such as central line and urinary catheter management bundles to reduce preventable patient harm due to infections. Our experience in the PfP work is that these bundles rarely consider the Organization (teamwork, communication, and culture) and instead focus more on Task (the insertion and extraction) and the Environment (sterile field). Still, infections occur usually as a result of job demands (workload resulting in workarounds), ineffective communication including the ability to “stop the line” when there were deviations from protocols, lack of patient/family engagement, poor signaling to promote timely removal, and poor team coordination. Integrating TeamSTEPPS assertion tools such as CUS* and the Two-Challenge Rule along with reminder technology to promote reliable removal adds the Organization and Technology elements to this bundle or process of care. In two years, central-line infections have been reduced by 45% across the member hospitals (Clark, 2014). Other focus areas such as adverse drug events, falls, pressure ulcers, and ventilator-associated pneumonia also have organizational elements critical to harm avoidance.
For clinical educators and physician practice leaders responsible for developing new skills and reinforcing best practices, integrating teamwork and communication skills into clinical skills training is essential for achieving safer outcomes.
With the North Carolina–Virginia HEN, we leveraged the power of team simulations with 30 hospitals to reduce preventable obstetrical harm. Here, the focus was not on technical skills alone but rather the essential TeamSTEPPS skills needed to optimally manage critical obstetrical and neonatal events such as a prolapsed cord, non-reassuring fetal heart rate, shoulder dystocia, lacerations, resuscitation, and post-partum hemorrhage. Experienced perinatal teams focused on developing teamwork and communication skills such as SBAR (situation-background-assessment-recommendation), check-backs, call-outs, and handoffs (handovers) between the labor & delivery team and the neonatal intensive care team. Significant positive changes in patient safety culture outcomes occurred among the teams using this integrated approach. Additionally, hospitals with obstetrical practices across the PfP program have experienced dramatic improvement in the reduction of early elective delivery (EED) rates—more than 50% EED reduction in two years (Clark, 2014). Communicating “hard stops” on early elective C-sections without medical indications requires greater team coordination, accountability, assertion, and a shared mental model—organizational elements, not just tasks.
For patient relations or patient experience leaders, omitting the Organization while focusing only on elements of the Environment, such as quiet hours or aesthetically pleasing artwork, probably won’t improve the majority of patient satisfaction indicators. At one of our urban client hospitals, improving patient satisfaction depended not only reducing wait times (Task and Technology) and improving the “look and feel” (Environment) but also Organization elements such as TeamSTEPPS team structure, which invites patients and families to become valued members of the patient care team. One significant change in process and task involved conducting bedside handoffs. Before including the patient and family, teams focused on improving their own handoff performance because now they had an audience, and patients can recognize the difference between effective and ineffective teamwork and communication. Frontline clinicians increased accountability while using an HCAHPS patient experience measure as an additional performance indicator. Post-implementation, the organization exceeded state and national benchmarks and has sustained their improvement goals related to the HCAHPS survey while simultaneously improving all patient safety culture survey dimensions.
I am sure many other readers of PSQH have had positive experiences with TeamSTEPPS over the past decade of performance improvement, and the research literature is full of success stories—many of which are posted on the TeamSTEPPS website (TeamSTEPPS, 2014). Although much more change and continuous improvement is needed in the areas of teamwork and communication in healthcare, it is encouraging to have a proven curricula and reliable approaches for integrating the TeamSTEPPS evidence-base tools and strategies into safer system design. Instead of simply responding to human error using the retrospective root cause analysis, healthcare organizations can prevent patient harm by implementing more proactive improvement approaches that create safer, healthier, and more resilient care systems for decades to come.
For more information on TeamSTEPPS® 2.0, visit the AHRQ website: http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html
Steve Powell has been a leader in human factors education, team performance, and communication training for 30 years in the U.S. Navy, commercial airline industry, and healthcare. He founded Synensis, formerly HTT, a human factors-based training and patient-centered safety consulting company. Powell was an original contributor to the TeamSTEPPS® – Strategies and Tools to Enhance Performance and Patient Safety program from 2005 to 2010 and served as a member of the TeamSTEPPS® Technical Expert Panel. He has supported the integration of TeamSTEPPS principles in more than 500 healthcare organizations in 11 countries. Powell serves on PSQH’s Editorial Advisory Board and may be contacted at spowell@synensishealth.com.
Footnotes
*For more information, visit http://www.kotterinternational.com/our-principles/our-iceberg-is-melting
*CUS stands for signal phrases used to communicate to team members, “I am Concerned. I am Uncomfortable. This is a Safety issue.”
References
Agency for Healthcare Research and Quality. TeamSTEPPS®: Strategies and Tools to Enhance Performance and Patient Safety, Author: Rockville, MD. Retrieved from http://www.ahrq.gov/qual/teamstepps/
Carayon, P., et al. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Healthcare, 15, Suppl. I, i50–i58.
Chassin, M. (2013). Improving the quality of health care: What’s taking so long? Health Affairs, 3 (10), 1761–1765.
Clark, C. (February, 2014). Hospital engagement networks lauded for lessening hospital harm, costs. Health Leaders Media. Retrieved from http://www.healthleadersmedia.com/page-1/QUA-300828/Hospital-Engagement-Networks-Lauded-for-Lessening-Hospital-Harm-Costs##
Jayanthi, A. (January, 2014). Patient safety tool: Leadership guide to implement safe practices. Becker’s Infection Control and Clinical Quality. Retrieved from http://www.beckershospitalreview.com/quality/patient-safety-tool-leadership-guide-to-implement-safe-practices.html
Kotter, J. (2006). Our iceberg is melting. New York: St. Martin’s.
Weaver, S., Dy, S. & Rosen, M. (2014). Team-training in healthcare: A narrative synthesis of the literature. BMJ Quality and Safety, 23, 359–372.