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Patient Safety Newsletter Spring 2008

Spring 2008 VOLUME 1, NUMBER 6: Patient Safety Tools: Teams, Teamwork, and Collaboration

Welcome to the sixth issue of Patient Safety Tools, IPRO's newsletter for resources, information, strategies, tools and best practices to help New York health care providers implement quality improvements that can drive transformational advances in patient safety.

Each issue of Patient Safety Tools examines one or more of the twelve "safety dimensions" for hospitals, as reflected in AHRQ's (Agency for Healthcare Research and Quality) Hospital Survey on Patient Safety Culture. This survey is available for any hospital to measure its own strengths and vulnerabilities on AHRQ's twelve dimensions of patient safety. With this assessment, hospitals can formulate a plan to promote sa- fety improvement using proven, evidence-based interventions.

This issue focuses on promoting teamworkⁱ as a way to cross the cultural boundaries and professional silos that pervade most hospitals and can make them unreceptive to implementing the kinds of changes that lead to safer, better care.

Hospital Teamwork - Room for Improvement

Review of the results of AHRQ's Hospital Survey in Patient Safety Culture shows that teamwork in hospitals is not what it could be (or should be).

More than 103,000 workers in 382 hospitals participated in the survey,ⁱⁱ which captured perceptions of teamwork within and across hospital units on eight measures. Here are the results:

On the surface, the results are mixed. On the one hand, teamwork within units received the highest average response (78%), indicating that this in an area of relative strength for hospitals. Indeed, one of the four measures within this dimension-"When a lot of work needs to be done quickly, we work together as a team to get the work done"-was the highest rated measure (85%) on the entire 42-item survey. On the other hand, teamwork across units ranked 9th lowest among the twelve dimensions with a composite score of 57%, indicating that this is an area of relative weakness for hospitals. One of the four measures in this dimension-"Hospital units do not coordinate well with each other"-ranked fifth lowest (44%) among the 42. Apparently, staff feel that people work together pretty well within their own units, especially when it's busy, but not so well with people from other units, whether it's busy or not.

Upon closer examination, these results are very revealing about current hospital culture, or rather cultures. First, although 78% of staff viewed themselves as working together well within their own units, 22% do not. This number does not bode well for the performance of team-based activities. If one out of five are not on board on any team, performance is likely to suffer. Picture a professional basketball team that fielded four team players and one doing his/her own thing. Needless to say, such a team would not win many games, no matter how well the four played together.

Second, the perception of teamwork between units is disturbingly low. Out of ten staff, six don't think units coordinate well with each other, four don't think that units that need to work together cooperate with each other, four think it's unpleasant to work with staff from other units, and three don't think patients get the best care because of units not working together well. In the environment described, work performance has to suffer. Performance in hospitals is measured by the safety and quality of the care delivered. Unfortunately, many patients are actually harmed during their hospital stays, with much of this harm attributable to miscommunication or lack of communication between units at handoffs and transitions.^{iii iv v}

Can this dynamic be changed? Hospitals are social organizations comprised of individuals and groups. The quality and safety of the care provided rests on the knowledge, skills, and actions of many people working in different areas over, nowadays, a few days. Each individual works within a learned, well-defined scope of practice, limited by the boundaries of their individual knowledge, training, experience, and skills. Some work alone, some in groups, some on unit- or function-based teams. Collectively, however, they do not always work together. They may not know each other and they may see each other rarely. They work apart, coming together only on occasion, typically when the stakes are highest and good communication means the difference between life and death.

Teams, Teamwork, and Collaboration

What differentiates a team from a workgroup? According to one source, a team is "...a small group of people with complementary skills committed to a common purpose and a set of specific performance goals. Its members are committed to working with each other to achieve the team's purpose and hold each other fully and jointly accountable for the team's results."^vi

While teams may differ in size, composition, goals, and work processes, they are special because they are designed to accomplish what individuals, workgroups, and staff cannot.

There are many kinds of teams in health care-clinical teams, management teams, leadership teams, quality improvement teams, patient safety teams. Some teams are better conceived, better trained, and do better than others. The best performing teams can improve performance in many aspects of the health care system. Recent evidence clearly demonstrates that teamwork can:

• Improve the quality of care^{vii viii}
• Improve patient safety^{ix x xi}
• Reduce staff shortages, stress, and burnout^xii
• Reduce workload^xiii
• Increase job satisfaction and retention^xiv
• Improve patient satisfaction^xv
• Reduce patient morbidity^xvi

Effective teams have been shown to share the following characteristics:^xvii

• Have a defined purpose. They begin with an end in mind and are structured and shaped to achieve that end. All team components- size, composition, location, processes, tools, duration, etc. -are based upon what is needed to carry out activities that contribute to achieving that end.
• Are serious about their purpose. It's the overarching reason they work together.
• Listen well. They engage in shared conversations, ask open-ended questions, show empathy, and provide feedback.
• Are respectful. They may disagree, may even conflict, but in a civilized fashion as they seek consensus. They understand that leadership is required, but may be shared.
• Communicate well, both internally and externally.
• Learn more deeply. They continually assess themselves, their activities, and their results. They examine, question, evaluate, iterate, and move on.
• Develop more solutions. They brainstorm, prioritize, decide, and test.
• Detect flaws more quickly. Teams use checklists. They're honest with each other.
• Build social connections. Teams create participation in their work, both internally and externally, formally and informally.
• Perform more reliably. They have clear roles and work assignments. They are committed to what they do and hold themselves and each other accountable for doing it.

So - if we believe that teams can improve hospital performance and, by implication, the quality of health care, why don't we build more teams? The simple answer is that it takes work to overcome our tendency, particularly in today's virtual world, to work autonomously, to hoard knowledge, and to maintain our individuality. Cultural barriers are hard to penetrate, but it's clear that the potential payoff is real.

Tools for Transitioning to a Team-Based Culture

The good news is that there is a growing evidence base that demonstrates that teams can and do succeed in health care environments and there are excellent tools available that make it possible to create and nurture a team-based working environment. The not-so-good news is that transitioning to a team-based culture requires a cultural shift that can only happen when there is a full-on commitment by everybody involved.

Frankel, et al, succinctly point the way. "To successfully apply and sustain effective teamwork and communication requires three components: visible and consistent senior leadership involvement, clinical physician leadership, and embedding the tools and behaviors in clinical work that people do every day."^xviii There are tools and techniques that can help any health care facility move forward.

TeamSTEPPS^TM, an evidence-based team performance program developed for the Department of Defense (DOD) and the Agency for Healthcare Research and Quality (AHRQ), is one of these tools. TeamSTEPPs is aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals. It includes a comprehensive set of ready-to-use materials and training curricula necessary to integrate teamwork principles successfully into your health care system. The program focuses on those critical tools and behaviors that support effective teamwork and collaborations - structured language, effective assertion/critical language, psychological safety, and effective leadership, among others - and allows time to practice the behaviors and skills taught.

TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety. Focusing on developing four core competencies-team leadership, situation monitoring, mutual support, and communication-the program has been extensively field tested for over two decades in both military and civilian health organizations and can be tailored for any health care setting. One of the most useful and now widely practiced and successful communication tools, SBAR (Situation-Background-Assessment-Recommendation), is one of several evidence-based strategies employed.

You can learn more about this program by clicking on this link - TeamSTEPPS^TM . This will bring you to an AHRQ Web page that contains further background information, describes the program's tools, allows you to order program materials, and provides a link to the DOD TeamSTEPPS Web site, where you can find additional detail. The program is recommended by CMS for any provider organizations wishing to dramatically improve teams, teamwork, and collaboration.

Stopping by woods on a snowy evening - one person's story experiencing teamwork in health care

IPRO's Project Leader Richard Corcoran, had a recent experience that gave him a chance to learn about health care teamwork first-hand. Here's his story, in his own words.

Consider colliding head-on with a deer at 55MPH in total darkness, seeing an actual "deer in the headlights" in your Toyota Corolla, hearing a dull thud, not in control, veering into the oncoming lane, seeing an SUV bearing down, being sideswiped, hearing the metallic, crunching sounds, not in control, and spinning, spinning, spinning to a complete stop in the middle of the road perpendicular to the edges and vulnerable, not in control. You see, hear, feel, and smell the air bag deploying, the seat-belt stiffening. You remain completely conscious and think to yourself "Am I conscious? Did I hit my head? Will I get hit again?"

You unbuckle your seat belt. Wonder why it takes so long, does not feel right, feels sore and achy and your right hand aches and your fingers point in disturbing directions you've never ever seen before and your chest hurts and your shoulders hurt when you try but can't open your door and you hurt even more when you lift yourself over the center console into the passenger seat and still can't open the passenger door and it's very cold and very dark When a voice yells suddenly - "Stop! Don't move! You're going to hurt yourself even more!"

This happened to me - January 17, 2006 5:30PM. That is the moment I began to experience our health care system for real, close up and personal, and over the course of the next few hours, days, and weeks came to better understand it's strengths, weaknesses, and vulnerabilities. And most of all came to a visceral understanding of just how important teams and all the elements of teamwork (communication, trust, honesty, motivation, multiple skills, information, speaking up) are to making health care better and safer.

Here's the short list of health providers in roughly chronological order for this one experience that began driving home from work, two miles from home, on a cold, dark country road on a cold, dark winter's night, proceeding by ambulance to the local ED, proceeding by ambulance to a major trauma center, to the OR, PACU, surgical unit, then back home, to a primary care office, to an orthopod, to a rehab center, then back to work six weeks later:

• First responders
• EMS crew
• Firefighters
• Ambulance crew
• Local, rural ED nurses and doctors
• Imaging tech
• Laboratory tech
• Cardiologist
• Surgeon
• Ambulance crew
• Trauma Center ED nurses and doctors
• Staff nurses
• Trauma teams
• Orthopedic teams
• Surgical Teams
• Imaging techs
• Laboratory techs
• Anesthesiologists
• Transport staff
• PACU teams
• Social worker
• Office staff
• Primary care physician
• Orthopedic physician
• Co-workers
• Imaging staff
• Hand therapists

Somewhere between 125-150 different people participated, some working alone, most working in some kind of group or team setting. Here's a short list of safety observations relating to teamwork and communication:

• First responders, ambulance crews, and firefighters work very well together.
• Firefighters are particularly good at safely ripping doors off of a totally demolished vehicle.
• Communication at hand-offs and transitions seems reasonably well done. Significant gaps and errors do occur, mainly due to incomplete documentation and the need to repetitively verify information with individuals who may be heavily medicated or in shock.
• Pain management following initial trauma is done, communicated, and documented very well. The use of the Wong-Baker "smiley face" pain rating scale is a particularly good tool.
• Medication reconciliation is pursued, but problematic due to the need for obtaining the same information by different providers using different documentation. Some focus only on prescribed medications and do not ask about over-the-counter.
• Patient identification is done correctly (asking two identifiers - name and DOB) about 80% of the time. Often, too often, you hear your name spoken first - "Are you...".
• Hand washing is visible and pursued vigorously by some, but not everybody.
• Wall-mounted gel dispensers and sterile gloves are prominent and available.
• Unfortunately, too many people do not stop to use them.
• Asking providers questions about the care they are delivering or about to deliver is way more important than advertised or promoted. The vignette below is an example.
• Well-prepared, proactive teams stand out against a background of individuals and less practiced teams trying, sometimes struggling, to do their best.

Here's what I remember about one brief interaction with two anesthesiologists just prior being wheeled to the Operating Suite.

Two anesthesiologists enter the room. I'm alone with morphine - no pain. They have a chart, look concerned, ask my name, look at the chart, and ask me what medications I'm taking. I respond. They look at the chart, unwrap the bandages on my right hand, the fingers don't look right to me, look at the chart, ask me what happened. I respond. They look at the chart and ask me would I prefer a nerve block or something else. I ask them to describe the nerve block. They tell me what a nerve block is and how they would do this and say something about injecting my right shoulder. They glance again at the chart and ask me about my TAA. I ask what's a TAA. Thoracic aortic aneurysm, they say. I immediately wake up and say I don't have a TAA. They look at each (confused?). One sits down and turns pages on the chart, pauses, and speaks to the other - "see, see right here, it says TAA." I say it must be wrong. I have never had a TAA. Call my doctor. They look at each other, then at me, then they both look at a page on the chart and say they will check about this. They ask me again what I would prefer. I choose a nerve block, sign something, and they leave. I begin to worry, but grow drowsier.

Though I worried a bit (well, a lot), I did not have a thoracic aortic aneurysm. My PCP was quick to get a repeat imaging study. Seems that the large amount of substernal bleeding made all the initial imaging studies difficult to interpret and one early ED provider had placed a single handwritten note on a report like this - TAA? Not a diagnosis, just a question!

The story ends well. With time, attention, and care - broken and repaired parts heal. We survive, learn, and move on. Lessons learned?

• The best health care teams listen well, pay attention to details, demonstrate commitment, and communicate effectively.
• Though teams and teamwork are not required to deliver every element of health care, they are absolutely essential most of the time and crucial to achieving good outcomes.
• Health care providers cannot do it alone. Each of us, individually, must fully participate on and collaborate with the teams that provide our care.

For more information, contact:

Richard Corcoran, Safety Project Lead, rcorcoran@nyqio.sdps.org

Charles Stimler, MD, MPH, Medical Officer, cstimler@nyqio.sdps.org

Marguerite Shaffer, RN, Senior Director, mshaffer@nyqio.sdps.org

Patient Safety Tools is produced by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy.

If you prefer not to receive future free electronic editions of Patient Safety Tools, it is easy to opt out. Send a blank email message to leave-ipro-pst-51700X@lists.ipro.us

Sources Consulted for this Newsletter

ⁱBaker DP, Gustafson S, Beaubien J, Salas E, Barach P. Medical Teamwork and Patient Safety: The Evidence-based Relation. Literature Review. AHRQ Publication No. 05-0053, April 2005. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/medteam/ ⁱⁱSorra J, Nieva V, Famolaro T, Dyer N. Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. (Prepared by Westat, Rockvlle, MD, under contract No. 233-02-0087, Task Order No. 18). AHRQ Publication No. 07-0025. Rockville, MD: Agency for Healthcare Research and Quality. March, 2007. ⁱⁱⁱAHRQ (Agency for Healthcare Research and Quality). 2005. National Healthcare Quality Report, 2005. AHRQ Publication No. 06-0018. Rockville, Md.: U.S. Department of Health and Human Services ^ivIOM (Institute of Medicine). 1999. To Err Is Human: Building a Safer Health Care System. Washington, D.C.: National Academy Press. ^v http://www.jointcommission.org/SentinelEvents/Statistics/ ^viKatzenbach, J and Smith, D. The Wisdom of Teams: Creating the High Performance Organization. Harvard University Press, 1996 ^viiUsha Subramanian, MD, MS; Jason Sutherland, PhD; Kimberly D. McCoy, MS; Karl F. Welke, MD; Thomas E. Vaughn, PhD; Bradley N. Doebbeling, MD, MSc Facility-Level Factors Influencing Chronic Heart Failure Care Process Performance in a National Integrated Health Delivery System. January 2007, Volume 45, Issue 1 ^viiiMorey, J.C., R. Simon, G.D. Jay, R.L. Wears, M. Salisbury, K.A. Dukes and S.D. Berns. 2002. Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project. Health Services Research 37(6): 1553-81. ^ixMarshall, D and Manus, D A Team Training Program Using Human Factors to Enhance Patient Safety AORN Journal Volume 86, Issue 6, Pages 994-1011 (December 2007) ^xPronovost, P., Berenholtz, S., et al. (2003). Improving communication in the ICU using daily goals. Journal of Critical Care, 18(2), 71-5. ^xiHoff T, Jameson L, Hannan E, and Flink E (2004). A review of the literature examining linkages between organizational factors, medical errors and patient safety. Medical Care Research and Review 61(1): 3-37. ^xiiIvy Oandasan Teamwork in Healthcare Promoting Effective Teamwork in Healthcare in Canada Policy Synthesis and Recommendations, Canadian Health Research Foundation, 2005 http://www.chsrf.ca/research_themes/pdf/teamwork-synthesis-report_e.pdf ^xiiiIbid ^xivIbid ^xvIbid ^xviBellomo R, Goldsmith D, Uchino S, Buckmaster J, Hart G, Opdam H, Silvester W, Doolan L, Gutteridge G: A prospective before-and-after trial of a medical emergency team. MJA 2003, 179:1-3. ^xvii http://tlt.its.psu.edu/suggestions/teams/student/benefits.html ^xviiiFrankel, A.S., Leonard, M.W., Denham, C.R. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability Health Services Research, August, 2006

Patient Safety Tools is produced by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-NY-TSK1C1-08-05

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