Strategies and Tools  to Enhance Performance  and Patient Safety
Ice Breaker
Sue Sheridan Video
Video Discussion <ul><li>How are patients harmed as a result of medical errors? </li></ul><ul><li>How can we prevent medic...
Objectives <ul><li>Describe the TeamSTEPPS training initiative </li></ul><ul><li>Explain your organization’s patient safet...
Teamwork Is All Around Us
Introduction <ul><li>Evolution of TeamSTEPPS </li></ul>  Curriculum Contributors <ul><li>Department of Defense </li></ul><...
<ul><li>“ Initiative based on evidence derived  from team performance…leveraging  more than 25 years of research in milita...
The Components of a  Patient Safety Program
Course Agenda <ul><li>Module 1 — Introduction </li></ul><ul><li>Module 2 — Team Structure </li></ul><ul><li>Module 3 — Lea...
Introductions and Exercise:  Magic Wand   If I had a “ Magic Wand ”  and could make changes within my unit or facility   i...
Why Do Errors Occur — Some Obstacles <ul><li>Workload fluctuations </li></ul><ul><li>Interruptions </li></ul><ul><li>Fatig...
Quality in Australian Healthcare Study  <ul><ul><li>Impact of Error: </li></ul></ul><ul><ul><li>Up to 16% of admissions as...
Medical Errors Still Claiming  Many Lives     <ul><ul><ul><ul><ul><li>… little progress towards the goal </li></ul></ul></...
Why Teamwork and Communication?  <ul><ul><li>Clinical handover is a high risk scenario for patient safety. Dangers include...
Sentinel Events in Victoria –  contributing factors from RCA   <ul><ul><li>Communication between the team e.g. clinical ha...
What Comprises Team Performance?   Knowledge Cognitions “Think” … team performance is a science…consequences of errors are...
Outcomes of Team Competencies <ul><li>Knowledge </li></ul><ul><ul><li>Shared Mental Model </li></ul></ul><ul><li>Attitudes...
Teamwork Actions <ul><li>Recognize opportunities to improve patient safety </li></ul><ul><li>Assess your current organizat...
Upcoming SlideShare
Loading in …5
×

Ts module 1_slides_introduction_06.1 vic_final2

645 views
542 views

Published on

Published in: Business, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
645
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
13
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Ts module 1_slides_introduction_06.1 vic_final2

  1. 1. Strategies and Tools to Enhance Performance and Patient Safety
  2. 2. Ice Breaker
  3. 3. Sue Sheridan Video
  4. 4. Video Discussion <ul><li>How are patients harmed as a result of medical errors? </li></ul><ul><li>How can we prevent medical errors? </li></ul><ul><li>What are the solutions? </li></ul> … Improved teamwork and communications… Ultimately, a culture of safety
  5. 5. Objectives <ul><li>Describe the TeamSTEPPS training initiative </li></ul><ul><li>Explain your organization’s patient safety program </li></ul><ul><li>Describe the impact of errors and why they occur </li></ul><ul><li>Describe the TeamSTEPPS framework </li></ul><ul><li>State the outcomes of the TeamSTEPPS framework </li></ul>
  6. 6. Teamwork Is All Around Us
  7. 7. Introduction <ul><li>Evolution of TeamSTEPPS </li></ul> Curriculum Contributors <ul><li>Department of Defense </li></ul><ul><li>Agency for Healthcare Research and Quality </li></ul><ul><li>Research Organizations </li></ul><ul><li>Universities </li></ul><ul><li>Medical and Business Schools </li></ul><ul><li>Hospitals—Military and Civilian, Teaching and Community-Based </li></ul><ul><li>Healthcare Foundations </li></ul><ul><li>Private Companies </li></ul><ul><li>Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM) </li></ul>
  8. 8. <ul><li>“ Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies ” </li></ul> Team Strategies & Tools to Enhance Performance & Patient Safety
  9. 9. The Components of a Patient Safety Program
  10. 10. Course Agenda <ul><li>Module 1 — Introduction </li></ul><ul><li>Module 2 — Team Structure </li></ul><ul><li>Module 3 — Leadership </li></ul><ul><li>Module 4 — Situation Monitoring </li></ul><ul><li>Module 5 — Mutual Support </li></ul><ul><li>Module 6 — Communication </li></ul><ul><li>Module 7 — Summary — Pulling It All Together </li></ul>
  11. 11. Introductions and Exercise: Magic Wand If I had a “ Magic Wand ” and could make changes within my unit or facility in the areas of patient quality and safety …
  12. 12. Why Do Errors Occur — Some Obstacles <ul><li>Workload fluctuations </li></ul><ul><li>Interruptions </li></ul><ul><li>Fatigue </li></ul><ul><li>Multi-tasking </li></ul><ul><li>Failure to follow up </li></ul><ul><li>Poor handoffs </li></ul><ul><li>Ineffective communication </li></ul><ul><li>Not following protocol </li></ul> <ul><li>Excessive professional courtesy </li></ul><ul><li>Halo effect </li></ul><ul><li>Passenger syndrome </li></ul><ul><li>Hidden agenda </li></ul><ul><li>Complacency </li></ul><ul><li>High-risk phase </li></ul><ul><li>Strength of an idea </li></ul><ul><li>Task (target) fixation </li></ul>
  13. 13. Quality in Australian Healthcare Study <ul><ul><li>Impact of Error: </li></ul></ul><ul><ul><li>Up to 16% of admissions associated with an adverse event </li></ul></ul><ul><ul><li>51% considered preventable </li></ul></ul><ul><ul><li>18% cause death or disability </li></ul></ul><ul><ul><li>The number of iatrogenic deaths exceeds the road toll </li></ul></ul> Cost associated with medical errors is $ 2 Billion per year (pre 2000) Action : Reporting of Sentinel Events Root Cause Analysis/ AIMS analysis Patient Safety Report Safety and Quality Projects – Clinical Practice Improvement Human Factors Engineering SA S&Q Council Action Areas Commission Priorities
  14. 14. Medical Errors Still Claiming Many Lives <ul><ul><ul><ul><ul><li>… little progress towards the goal </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Leape and Berwick, JAMA May 2005 </li></ul></ul></ul></ul></ul>
  15. 15. Why Teamwork and Communication? <ul><ul><li>Clinical handover is a high risk scenario for patient safety. Dangers include discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008). </li></ul></ul><ul><ul><li>Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005). </li></ul></ul><ul><ul><li>An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007). </li></ul></ul><ul><ul><li>A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004). </li></ul></ul><ul><ul><li>Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007). </li></ul></ul>
  16. 16. Sentinel Events in Victoria – contributing factors from RCA <ul><ul><li>Communication between the team e.g. clinical handover </li></ul></ul><ul><ul><li>Communication between staff and patient/family </li></ul></ul><ul><ul><li>Cultural diversity (involvement of interpreters) 1 </li></ul></ul>Communication was cited in sentinel events RCA reports as a major contributing factor from 2002/03 (16% of reports) to 2008/09 (20% of reports) and related to: 1. www.health.vic.gov.au/clinrisk/downloads/sentinel_event_program_0809.pdf (accessed 27/9/2010)
  17. 17. What Comprises Team Performance? Knowledge Cognitions “Think” … team performance is a science…consequences of errors are great… Attitudes Affect “Feel” Skills Behaviors “Do”
  18. 18. Outcomes of Team Competencies <ul><li>Knowledge </li></ul><ul><ul><li>Shared Mental Model </li></ul></ul><ul><li>Attitudes </li></ul><ul><ul><li>Mutual Trust </li></ul></ul><ul><ul><li>Team Orientation </li></ul></ul><ul><li>Performance </li></ul><ul><ul><li>Adaptability </li></ul></ul><ul><ul><li>Accuracy </li></ul></ul><ul><ul><li>Productivity </li></ul></ul><ul><ul><li>Efficiency </li></ul></ul><ul><ul><li>Safety </li></ul></ul>
  19. 19. Teamwork Actions <ul><li>Recognize opportunities to improve patient safety </li></ul><ul><li>Assess your current organizational culture and existing Patient Safety Program components </li></ul><ul><li>Identify teamwork improvement action plan by analyzing data and survey results </li></ul><ul><li>Design and implement initiative to improve team-related competencies among your staff </li></ul><ul><li>Integrate TeamSTEPPS into daily practice. </li></ul> “ High-performance teams create a safety net for your healthcare organization as you promote a culture of safety.&quot;

×