This document discusses strategies and tools for effective communication to enhance team performance and patient safety. It introduces TeamSTEPPS, a teamwork system developed by the Department of Defense and Agency for Healthcare Research and Quality to improve communication and other teamwork skills among healthcare professionals. Specific communication strategies described include SBAR, call-outs, check-backs and handoffs. Effective communication is identified as a key factor in patient safety and reducing medical errors.
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Objectives
Describe the importance of communication
Recognize the connection between communication
and medical error
Discuss The Joint Commission national patient safety
goals
Define communication and discuss the standards of
effective communication
Describe strategies for information exchange
Identify barriers, tools, strategies, and outcomes to
communication
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Teamwork Is All Around Us
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50%
Reduction
50%
Reduction
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
Length of ICU Stay After Team Training
50%
Reduction
(Sexton, 2006)
Johns Hopkins
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine
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Introduction
Evolution of TeamSTEPPS
Curriculum Contributors
• Department of Defense
• Agency for Healthcare
Research and Quality
• Research Organizations
• Universities
• Medical and Business
Schools
• Hospitals—Military and
Civilian, Teaching and
Community-Based
• Healthcare Foundations
• Private Companies
• Subject Matter Experts in
Teamwork, Human Factors,
and Crew Resource
Management (CRM)
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“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”
Team
Strategies & Tools to Enhance Performance & Patient Safety
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2006
Patient Safety
and Quality
Improvement
Act of 2005
Patient Safety Movement
Executive
Memo from
President
DoD
MedTeams®
ED Study
Institute for
Healthcare
Improvement
100K lives
Campaign
“To Err
is Human”
IOM Report TeamSTEPPS
1995 1999 2001 2003 2004 2005
JCAHO
National Patient
Safety Goals
Medical Team Training
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The Components of a
Patient Safety Program
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Why Do Errors Occur—Some Obstacles
Workload fluctuations
Interruptions
Fatigue
Multi-tasking
Failure to follow up
Poor handoffs
Ineffective
communication
Not following protocol
Excessive professional
courtesy
Halo effect
Passenger syndrome
Hidden agenda
Complacency
High-risk phase
Strength of an idea
Task (target) fixation
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What Comprises Team Performance?
Knowledge
Cognitions
“Think”
…team performance is a
science…consequences
of errors are great…
Attitudes
Affect
“Feel”
Skills
Behaviors
“Do”
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Outcomes of Team Competencies
Knowledge
Shared Mental Model
Attitudes
Mutual Trust
Team Orientation
Performance
Adaptability
Accuracy
Productivity
Efficiency
Safety
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Teamwork Actions
Recognize opportunities to improve patient safety
Assess your current organizational culture and
existing Patient Safety Program components
Identify teamwork improvement action plan by
analyzing data and survey results
Design and implement initiative to improve team-
related competencies among your staff
Integrate TeamSTEPPS into daily practice.
“High-performance teams create a safety net for
your healthcare organization as you promote a
culture of safety."
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Teamwork Encompasses CRM
DoD has led the way in team research and innovations
Non-Healthcare
Combat Information Centers
Joint Forces Operations
Emergency Management Communities
Army Special Forces
Tank, Submarine, and Air Crews
Healthcare
ED, OR, L&D, ICU, Dental
Whole Hospital
Combat Casualty Care
CRM
Team
Training
…striving to be a high reliability healthcare system…
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Background: US Army Aviation
Army aviation crew coordination failures in mid-80s
contributed to 147 aviation fatalities and cost more
than $290 million
The vast majority involved
highly experienced aviators
Failures were attributed largely
to crew communication,
workload management, and
task prioritization
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US Navy Breakthroughs: Tactical
Decisionmaking Under Stress (TADMUS)
Cross-Training
Stress Exposure Training
Team Coordination
Training (CRM)
Scenario-Based Training
and Simulation
Team Leader Training
Team Dimensional Training
Team Assessment
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US Air Force CRM History
Mid to Late 80s AF bombers
and heavy aircraft started
CRM training
1992 Air Combat Command
developed Aircrew Attention
Management /CRM Training
By 1998, CRM deployed
uniformly across the AF
Steady decline in human
factors based mishaps since
CRM training deployed
AF Medical Service adapted
training, rolled out in 2000
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John Kotter
Eight Steps
of Change
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Catalytic event drives
need for change
Build team,
strategy, buy-in,
establish goals
Implement Action Plan,
Train, Empower Others
TeamSTEPPS
Change
Coaching
I’m staying
right here.
Yeah they’ll be
back.
What
are they
doing?
Why do
we need
change
?
Jt. Comm.
Status QUO
FUTURE
Errorville
Celebrate wins!
Staying the course
Sustaining
Develop Action
Plan
Test
Intervention
(Outcomes)
Monitor, Integrate, Continuous
Process Improvement
Prepare
the Climate
Roadmap to a
Culture of Safety
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Are better able to predict the needs of other team
members
Provide quality information and feedback
Engage in higher level decision-making
Manage conflict skillfully
Understand their roles and responsibilities
Reduce stress on the team as a whole through
better performance
“Achieve a mutual goal through
interdependent and adaptive actions”
Effective Team Members
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Team Events
Briefs – planning
Huddles – problem solving
Debriefs – process improvement
Leaders are responsible to assemble the team
and facilitate team events
But remember…
Anyone can request a brief, huddle, or debrief
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Briefs
Planning
Form the team
Designate team roles
and responsibilities
Establish climate and
goals
Engage team in short
and long-term planning
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Planning Essentials for Teams
Leader usually initiates the planning process
Team members are included in the planning
process
Team members have a common
understanding of the problem and their roles
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TOPIC
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
Briefing Checklist
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Huddle
Problem solving
Hold ad hoc, “touch-base”
meetings to regain
situation awareness
Discuss critical issues
and emerging events
Anticipate outcomes
and likely contingencies
Assign resources
Express concerns
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Debrief
Process Improvement
Brief, informal information exchange and
feedback sessions
Occur after an event or shift
Designed to improve teamwork skills
Designed to improve outcomes
An accurate reconstruction of key events
Analysis of why the event occurred
What should be done differently next time
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TOPIC
Communication clear?
Roles and responsibilities
understood?
Situation awareness
maintained?
Workload distribution?
Did we ask for or offer
assistance?
Were errors made or
avoided?
What went well, what
should change, what
can improve?
Debrief Checklist
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Facilitating Conflict Resolution
Effective leaders facilitate conflict
resolution techniques through invoking:
Two-Challenge rule
DESC script
Effective leaders also assist by:
Helping team members master conflict
resolution techniques
Serving as a mediator
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Leadership
OUTCOMES
Shared Mental
Model
Adaptability
Team Orientation
Mutual Trust
BARRIERS
Hierarchical
Culture
Lack of Resources
or Information
Ineffective
Communication
Conflict
TOOLS and
STRATEGIES
Brief
Huddle
Debrief
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Teamwork Actions
Empower team members to speak freely
and ask questions
Utilize resources efficiently to maximize
team performance
Balance workload within the team
Delegate tasks or assignments, as appropriate
Conduct briefs, huddles, and debriefs
Utilize conflict resolution techniques
(i.e., Two-Challenge rule and DESC script)
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The Joint Commission: Importance
of Communication
Ineffective communication is a
root cause for nearly 66 percent
of all sentinel events reported*
* (The Joint Commission Root Causes and Percentages
for Sentinel Events (All Categories) January
1995−December 2005)
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Joint Commission Goals That Relate
To Communication
National Patient Safety Goals (NPSGs) related to
communication:
Improve the effectiveness of communication among
caregivers
Read-Back
Handoff
Accurately and completely reconcile medications and
other treatments across the continuum of care
Address specifically during handoff
Encourage the active involvement of patients and their
families in the patient’s care, as a patient safety strategy
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The process by which information is exchanged
between individuals, departments, or organizations
The lifeline of the
Core Team
Effective when it
permeates every
aspect of an
organization
Communication is…
Assumptions
Fatigue
Distractions
HIPAA
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Standards of
Effective Communication
Complete
Communicate all relevant information
Clear
Convey information that is plainly understood
Brief
Communicate the information in a concise manner
Timely
Offer and request information in an appropriate timeframe
Verify authenticity
Validate or acknowledge information
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Brief Clear
Timely
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Information Exchange Strategies
Situation–Background– Assessment–
Recommendation (SBAR)
Call-Out
Check-Back
Handoff
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SBAR provides…
A framework for team members to effectively
communicate information to one another
Communicate the following information:
Situation―What is going on with the patient?
Background―What is the clinical background or
context?
Assessment―What do I think the problem is?
Recommendation―What would I recommend?
Remember to introduce yourself…
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SBAR Example
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Call-Out is…
A strategy used to communicate
important or critical information
It informs all team members
simultaneously during
emergency situations
It helps team members
anticipate next steps
…On your unit, what information
would you want called out?
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Check-Back is…
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Handoff
The transfer of information (along with authority and
responsibility) during transitions in care across the
continuum; to include an opportunity to ask questions,
clarify, and confirm
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Reporting Tools:Handoff
Optimized Information
Responsibility– Accountability
Uncertainty
Verbal Structure
Checklists
IT Support
Acknowledgement
Great opportunity for
quality and safety
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“I PASS THE BATON”
IIntroduction: Introduce yourself and your role/job (include patient)
PPatient: Identifiers, age, sex, location
AAssessment: Present chief complaint, vital signs, symptoms, and
diagnosis
SSituation: Current status/circumstances, including code status,
level of uncertainty, recent changes, and response to treatment
SSafety: Critical lab values/reports, socio-economic factors, allergies, and alerts
(falls, isolation, etc.)
THE
BBackground: Co-morbidities, previous episodes, current medications, and family history
AActions: What actions were taken or are required? Provide brief rationale
TTiming: Level of urgency and explicit timing and prioritization of actions
OOwnership: Who is responsible (nurse/doctor/team)?
Include patient/family responsibilities
NNext: What will happen next? Anticipated changes?
What is the plan? Are there contingency plans?
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ISHAPED – Another Report Tool
I: Introduction
S: Story
H: History
A: Assessment
P: Plan
E: Error-Prevention
D: Dialogue
* From Inova/Picker Institute available at: http://alwaysevents.pickerinstitute.org/?p=1251
46
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Communication Challenges
Language barrier
Distractions
Physical proximity
Personalities
Workload
Varying communication styles
Conflict
Lack of information verification
Shift change
Great
Opportunity for
Quality and Safety
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Barriers to Team Effectiveness
TOOLS and
STRATEGIES
Brief
Huddle
Debrief
STEP
Cross Monitoring
Feedback
Advocacy and Assertion
Two-Challenge Rule
CUS
DESC Script
Collaboration
SBAR
Call-Out
Check-Back
Handoff
OUTCOMES
Shared Mental Model
Adaptability
Team Orientation
Mutual Trust
Team Performance
Patient Safety!!
BARRIERS
Inconsistency in Team
Membership
Lack of Time
Lack of Information Sharing
Hierarchy
Defensiveness
Conventional Thinking
Complacency
Varying Communication Styles
Conflict
Lack of Coordination and
Follow-Up with Co-Workers
Distractions
Fatigue
Workload
Misinterpretation of Cues
Lack of Role Clarity
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Teamwork Actions
Communicate with team members in a brief,
clear, and timely format
Seek information from all available sources
Verify and share information
Practice communication tools and strategies daily
(SBAR, call-out, check-back, handoff)