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HANYS Teamwork – Technique: Achieving Critical Care Excellence
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HANYS Teamwork – Technique: Achieving Critical Care Excellence

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  • Creating a Team (Objectives)
    By not only knowing your own responsibilities, but also the responsibilities of the entire staff, a more effective team will be formed.
    This seems logical enough, but in our jobs sometimes we focus only our own areas of concern, and ignore the areas of concern for our team members.
    Participation in and of itself lends to better team formation.
    Getting involved in all aspects of the procedure can only enhance the outcome.
    On top of this we will also give some techniques to aid in team formation.
    “You are already doing many of the things that we will discuss.
    What we want to do is give you skills, specific things that you do or say, that will improve the performance of the team and the individuals that make up the team.
    How many of you have had your tires changed recently? How long did it take? I would like to show you a team that can change tires in less than 15 seconds!
    I have a video I’d like you to watch…how many of you are familiar with auto racing? How many of you recognize the name “Michael Andretti”? He is one of the all time most successful race car drivers in history, and he can’t do it by himself.
    He needs a pit crew right? Hopefully most of you know what a pit crew does…they can change all four tires, adjust shock settings, fill the gas tank, clean the windshield, give the driver a drink, and make other minor adjustments and FINISH within 15 seconds. Since many races are won by split second margins, the effectiveness of the pit crew can make all the difference.
    Can anyone walk off the street and be a pit team member? No way! It takes years of experience and hundreds or thousands of repetitions to get every action done to perfection. As you would expect, Michael Andretti has one of the best pit crews in racing…watch this video of an actual race, with his crew in action.
  • The lesson-learned is
    That all teams have processes that can be improved.
    You need to be aware that the formation of a team happens very quickly and might not progress the way that you want it to without some basic elements.
    Transition:
    “Let’s look at another video showing a Team Leader’s actions while forming a Team. How many of you have flown with a commercial air line over the past year? Note that the crew that flew that aircraft came together for the very first time, just about an hour prior to your flight. Prior to that, most had never met. Within that hour, they must effectively form a team able to handle any potential contingency. Let’s see how they do.”
  • Scenario:
    Prior to the video
    You will see three men in this video… first, the captain and the copilot. Later, you will first see the copilot and the flight engineer. Lastly, the captain will walk on board the aircraft while the copilot and flight engineer are talking
    After the video
    Have any of you ever been in a procedure where the person in charge acted the same way? How did you feel as a part of that team?
    How effective was this crew at establishing an effective team?
    Was there any team formation at all?
    How about the team formed by the copilot and flight engineer?
    Was that an effective way to form a team?
    A Team was formed, but it was not an effective Team.
    The Copilot and the Engineer were actually working AGAINST the Captain.
    “Was this Team really prepared to work together? Why is this important?”
    Go over each point individually and get class input on whether they have seen Teams that function like this one.
    TRANSITION
    What do you suppose could happen if team formation was INEFFECTIVE ?
  • The lesson-learned is
    That all teams have processes that can be improved.
    You need to be aware that the formation of a team happens very quickly and might not progress the way that you want it to without some basic elements.
    Transition:
    “Let’s look at another video showing a Team Leader’s actions while forming a Team. How many of you have flown with a commercial air line over the past year? Note that the crew that flew that aircraft came together for the very first time, just about an hour prior to your flight. Prior to that, most had never met. Within that hour, they must effectively form a team able to handle any potential contingency. Let’s see how they do.”
  • Why must you create a team ?
    It will happen anyway – so why not create an effective Team?
    Isn’t that what happened in the movie? Is it unrealistic to assume that the same things happen to medical teams?
    Complex environment – one person can’t do it all.
    Large aircraft require more than one crew member. There is instrumentation in the cockpit that cannot even be reached by one of the other crew members.
    Does your medical team require more than one person? Why?
    Creates personal responsibility – each team member has a stake in the outcome
    In aviation, each crew member has a personal stake in the outcome. If the outcome is catastrophic, all die! Is there a parallel to your medical team?
    Even though medical team members do not usually die as a result of team error, all members share in the responsibility for a safe and effective patient outcome.
    Better chance of catching / correcting errors
    If I work with you every day, and I know what must be done, I know what to expect from the team. If I see something out of the ordinary, I know it!
    TRANSITION
    Of course, there are benefits to being a member of a highly effective team. What might some of those benefits be?
  • Use inter-personal skills -Cover this as the starting point, emphasize most of you do this already.
    Introduce yourself - make basic introductions; important to know to whom communications are being addressed. If you think you know everyone’s name, try it some day when there’s an extra resident, extra fellow, student med tech, agency nurse, etc.
    Make eye contact; If there is no eye contact, you are missing 50% of the meaning of the message (won’t see body language);
    STORY: There was a DC-10 crew (Captain, Copilot, and Flight Engineer) flying up to Anchorage for a layover – about an 8 hour flight. The Engineer went to a local sports bar after checking in at the hotel and got some food and drink. Shortly after, another individual sat down next to him and struck up a conversation. The other person asked general questions like his name, profession, why he was in Anchorage, etc, and was surprised to learn that they both flew the same airplane for the same company. The engineer asked, “Why are you surprised…I was YOUR FLIGHT ENGINEER ON THE WAY UP HERE!”
    Learn names; to whom are you communicating?
    Ensure action supports words. Actions do speak louder than words and you can’t say you want input if you really don’t. Body language and tone will betray your real intent.
    Transition:
    “What else is needed?”
  • Clearly provide / understand the big picture in a “Pre-Brief”
    Take that 2 to 6 minutes and ensure the entire team is on the same sheet of music.
    Providing the big picture is probably the most important thing the Team Lead can do.
    You cannot afford NOT to take the time to do this.
    Outline the procedure / situation
    Discuss critical points
    If you need to shift emphasis at a certain point in the procedure, where are the transition points… e.g., when can I transition from stopping the bleeding to getting the patient a bed?
    Specify duties
    Don’t just assume all know their respective positions.
    Anticipated outcome
    How about talking about the outcome expected and how long you expect that to take? What do you expect of the patient following the procedure? Will we put him/her in the ICU, or will we send them home?
    Plan / discuss most likely contingencies
    Finally, what is the most likely thing that can go wrong? Are we prepared for that? Do I know what is expected of me if that happens?
    Transition:
    “There are more skills that lead to Creation of that truly effective Team…”
  • Invite participation from the team
    Explicitly ask Team members to provide information, express their concerns, and speak up when necessary
    Is it really necessary to do this? Everybody knows you’re a nice person. Won’t they speak up anyway? Probably not.
    Why not? Learned behavior from past experiences. Suffered the ire of a team leader that was determined to do it his way.
    What happens the first time a team member provides input and that input is ignored? (Probably the last time input will be made)
    If you ask for input and mean it, questions asked by the team are a good way to verify their understanding.
    Encourage the Team to ask questions to verify their understanding
    If team members are comfortable asking questions, they will be more likely to do so when/if things look like they are going wrong.
    TRANSITION:
    Good Communication is also extremely important…
  • Effective Team Skills
    Information flow
    Is critical if the Team is to be successful.
    Ask the Staff for examples of how this can improve their performance.
    Ask questions to check understanding and begin two way communications
    Explain that the pattern of response and asking of specific questions
    Designed to start the communication flow before the flow becomes critical.
    Teams that are not communicating effectively before a crisis cannot communicate effectively during a crisis.
    To set up a pattern of response, ask team members for information they should know, that requires more than a yes or no answer and do not settle for a yes or no answer. Team members know you are going to hold them accountable for certain information. Do this early on, so the first time you are seeking information from a team member is not during a critical event.”
    Ask questions that require more than a YES or NO response
    YES and NO responses reveal very little. If you ask a team member to describe a particular procedure, you will ultimately know much more about what THEY know than if you simply just ask if they understand.
    Transition:
    The other part of communication is critical for both team leaders and team members…
  • Acknowledging all communication
    …and that is acknowledging all communication. Why is this necessary? (person will assume you heard and understood what they said)
    This acknowledgement may be verbal or visual (seeing someone taking the appropriate action)
    This step is critical for informing the rest of the Team as to what is going on.
    In healthcare, there are already specific communications which must be acknowledged. One example is verifying blood products as appropriate to the patient. One person hands the blood to another reciting the type. The receiving person must also read and recite the blood type.
    TRANSITION:
    Nobody can predict the future (click), but you can…
  • Next slide: Break….

Transcript

  • 1. HANYS Teamwork – Technique: Achieving Critical Care Excellence Teambuilding for Critical Care TeamsTeambuilding for Critical Care Teams
  • 2. Objectives • Use four leadership strategies to structure the organization to permanently support and enable effective teamwork among caregivers • State the benefits of effective teamwork among critical care teams; • Use five key action steps to create and maintain great teamwork; • Understand how to hardwire teamwork behaviors into daily operations;
  • 3. The 4 P’s • Philosophy • Policy • Procedure • Practice Four leadership strategies to structure the organization to permanently support and enable effective teamwork among caregivers
  • 4. Understand that Great Teamwork (as a Key Component of Safety and Quality) in Critical Care is a Function of Philosophy, Policy, Procedure, and Practice
  • 5. Philosophy An over-arching view of how the business of the hospital will be conducted
  • 6. Sample Philosophy Statements • “General Hospital provides care that is safe, efficient, patient-centered, timely, effective, and equitable. To do this, we will excel technically, be experts in teamwork, and follow our policies, procedures, and protocols to provide the highest standard of care.” • “Memorial Hospital provides safe, efficient, compassionate care of the highest standard through teamwork, technical proficiency, and adhering to guidelines, policies, and procedures.” • Notice that each statement has two parts: “What” and “How”
  • 7. Policy Broad specifications of the manner in which management expects things to be done
  • 8. “All members of the surgical services team at Vanderbilt will be trained in CRM skills and are expected to use these CRM skills in their daily work and in their professional communication with other members of the Vanderbilt healthcare organization.” Vanderbilt University OR Guidelines Sample Policy Statement
  • 9. “All on-duty members of the NICU team at General Hospital are expected to attend and participate in the Morning Shift Briefing. The Briefing shall be conducted using the approved briefing guide.” General Hospital NICU Guidelines Sample Policy Statement
  • 10. Procedures An established or correct way of doing something
  • 11. Sample Procedure
  • 12. What the human operator actual does in the daily work environment Practices
  • 13. Practices • Encompass every activity conducted in the hospital: • Correct execution of a procedure • Deviation from a procedure • Omission of a procedure • The use of a technique (authorized or not) The human operator’s decisions and actions determine the system outcome
  • 14. • Conforming To, or Deviating From •Cannot assume that teams will follow any given procedure dictated by management –Must be checked or measured through “rounding” or data collection/analysis Practices
  • 15. Practices Team Deviate Deviate Conform Practices
  • 16. • Goal of Leadership/Management – Minimize deviations in Practices by… • Promoting good practices by specifying coherent procedures • Ensuring Procedures are consistent with Policy • Ensuring Policy is consistent with Philosophy Practices
  • 17. • Leadership Actions to Minimize Deviations • Rounding (Checking) • Project Interviews • Reinforcing and Publicizing Positive Behavior • Dealing With Low Performers • Measuring Practices
  • 18. Creating the “Chemistry” Needed for Great Teamwork
  • 19. • Study of 23 NBA teams from 1980 – 1994 • Results? Greater roster stability (fewer trades and player turnover) = better won/loss record (Berman et al, 2002) Basketball is a “Chemistry Sport”
  • 20. Commercial Aviation is a “Chemistry Sport” • Risk Factors • First day • First flight • Night time • Visual approach flown by Captain
  • 21. Video Does this team have the “Chemistry” for a safe flight?
  • 22. Is Healthcare a “Chemistry Sport?” • Harvard study of 38,577 procedures by 203 surgeons in 43 hospitals • Compared outcomes at facilities where surgeons do a lot of procedures vs. where they do fewer • Surgical skill is “not portable” • Better pt. outcomes where surgeons have more experience with their teams • “Familiarity helps the surgeon perform better.” (Huckman & Pisano, 2006)
  • 23. The Value of Creating “Chemistry” • Creating and tapping the “Collective Mind” to detect & correct potential errors • Relevant information • Mastery of tools and knowledge • Understanding of tasks (Liang et al, 1995) • Better Care • Better teams have 12% fewer avoidable complications and 21% fewer avoidable deaths (Gallop, 2006)
  • 24. How can you build team chemistry in a reliable and repeatable way?
  • 25. Building Team Chemistry • Use inter-personal skills • Introduce yourself • Make eye contact when communicating • Learn names so they can be used during the procedure or critical times during the shift
  • 26. Building Team Chemistry • Clearly provide / understand the big picture in a “Pre-Brief” • Outline the procedure / situation • Discuss critical points • Specify duties • Anticipated outcome • Plan / discuss most likely contingencies
  • 27. Building Team Chemistry • Invite participation from the Team • Explicitly ask team members to provide information, express their concerns, and speak up when necessary • Encourage the team to ask questions to verify their understanding
  • 28. Building Team Chemistry • Ask questions to check understanding and begin two- way communication • Set up a “pattern of response” • Ask questions that require more than a “Yes” or “No” response
  • 29. Building Team Chemistry • Acknowledge all communication • Close the “loop” • Confirms understanding
  • 30. Using these skills “at the bedside” • Implement an Expanded Briefing conducted with a Checklist • Why? • Better performance and care • Kaiser Permanente reported 50% cut in unexpected delays, RN turnover from 19% to zero, elimination of wrong surgeries (Defontes, 2004) • “…useful quality improvement tool…” (Altpeter et al, 2007) • “…effective tool in promoting teamwork among surgery staff members…” (Makary et al, 2007)
  • 31. Model Briefing Format Offered by JACS  Names & roles of team members  Conduct Time Out procedures  Antibiotics  Review of critical steps  Review potential problems  Safety Statement*  Names & roles of team members  Conduct Time Out procedures  Antibiotics  Review of critical steps  Review potential problems  Safety Statement* (Markary et al, 2007)
  • 32. Evaluate this team…
  • 33. Evaluate this team • Used interpersonal skills? • Eye contact, body language, names, etc. • Provided Big Picture – contingencies etc? • Invited participation? • Asked open ended questions? • Acknowledged communications?
  • 34. Action List • Determine your philosophy of care – get it in writing • Revise your P&P Manual or Department Policies to support the teamwork behavior you desire • Ensure your care givers are trained in the desired teamwork skills • Create “hardwired tools” to require and support the use of those teambuilding behaviors • Build a system of “rounding” to check and reinforce the desired behaviors
  • 35. Thank You www.SaferPatients.com