PERIOPERATIVE LEADERSHIP
Stepping Up Teamwork via TeamSTEPPS CYNTHIA PLONIEN, DNP, RN, CENP; MARCIE WILLIAMS, MS, RN, FASHRM, CPHRM
P
erioperative leaders are in the spotlight to develop and manage effective and safe teams caring for patients in the OR setting. Leadership does not begin and end with personnel reporting to nurse managers. It must involve every member of the OR team with a connection to the patient during a surgical procedure, inclusive of physicians and vendors. The OR is a complex environment in which effective communication and the coordination of multiple team members can be critical for safe and efficient functioning. Team members rely on one another’s expertise for completing tasks successfully. They must share information rapidly when responding to expected and unexpected events. Mistakes in communication are cited by The Joint Commission as the principle underlying cause of human error.1 Improved teamwork and communication have been identified as a priority by The Joint Commission and Agency for Healthcare Research and Quality (AHRQ).1,2
been developed by the AHRQ and the Department of Defense to improve quality and safety in health care.2 The TeamSTEPPS tool is an open resource that is available and free of charge for administrators and managers. Implementation of new processes that require a change in behavior is seldom easy. However, numerous organizations have been very successful in using TeamSTEPPS as an evidence-based method to enhance clinical communication within teams and improve patient outcomes in the OR. The focus of this column is an overview of TeamSTEPPS, inclusive of recommendations for successful implementation by OR executives and leaders who are intent on increasing safety as well as efficiency in the OR setting by improving team performance.
Teamwork tools, such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), have
TeamSTEPPS had its beginnings with crew resource management (CRM), a set of training procedures incorporated into
EVOLUTION OF TEAMSTEPPS
http://dx.doi.org/10.1016/j.aorn.2015.01.006 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 465
PloniendWilliams
a 1973 National Aeronautics and Space Administration workshop designed to increase air travel safety and reduce fatal accidents attributed to human error.3 Aviation disasters of the 1970s triggered an innovative shift from errors attributed to mechanical failure or pilot training to errors attributed to communication to prevention of error through CRM and improved team communication. At that time, studies had identified the primary cause of fatal airline accidents as human error.3,4 Specifically, the cause was found to be failures in the cockpit related to communication, leadership, and decision making. Further study of airline accidents identified that 70% of commercial airline accidents were attributed to communication errors.4 For example, in 1977, an incident occurred when two Boeing 747s collided on a runway with another, and 582 lives were lost. One of the pilots mistakenly thought the preflight checklist had been completed and attempted take off without clearance. The tragedy traced back to human error. The critical nature of communication in aviation with resulting error is similar to outcomes that have been observed in health care. A high rate of human error with disastrous results to quality also occurs in health care. Public awareness of health care quality reached a critical mass after publication of the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System.5 The report concluded that medical errors result in an estimated 98,000 preventable deaths annually.5 Subsequent to the report, evidence-based research, as well as governmental and accreditation organizations, has cited the importance of teamwork and communication in patient safety.
OR TEAMS It is of no surprise to OR leaders that effective communication and teamwork are essential for safe care and avoidance of error resulting in harm. Teams can be defined as a group that share a cognitive common ground and solve unique problems by coordinated action, often in a dynamic setting where protocols and checklists are not applicable.6(p398) Teamwork, in this sense, is a critical aspect of patient care in the OR.6 Historically, quality and safety leadership was left to the expert practitioner, the surgeon. However, as evidence has shown, teams make better decisions than do individuals. In regard to safety, the surgeon is no longer the “captain of the ship.” Today’s ORs consist of countless individuals working together to perform high-risk tasks, and each member of the team has a responsibility to protect the patient. In ensuring safety, an OR leader is supported by standardized tools and an environment in which individuals can speak up to share concerns and alert members of the team to unsafe 466 j AORN Journal
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conditions. The TeamSTEPPS methodology employs a common language in communication together with associated protocols proved to result in improved patient safety outcomes.
RESEARCH Considerable research has been published regarding the improvements realized after medical team training. In the perioperative environment, two specific TeamSTEPPS toolsdbriefings and debriefingsdseem to provide the most benefit in improving effective communication among OR team members and improving the actual operations of the department. One of the largest published research projects related to the application of briefings and debriefings after medical team training is an analysis of 4,863 cases.7 After OR team training with surgeons, anesthesia professionals, and perioperative personnel, preoperative briefings were conducted in the OR before the incision was made. The project was led by the surgeons, with opportunities for all team members to provide input. To encourage speaking up, the surgeon asked if anyone had any concerns; this is a new approach used in the OR setting, which is known for its strict hierarchical environment. The purpose of the project was for the entire team to understand the following key performance goals: ensure that preoperative preparation is complete and focuses on site-specific needs, identify critical steps for possible complications, and promote communication and teamwork throughout the procedure. In addition, postoperative debriefings were conducted after the surgical procedures were completed but before the team left the OR. The RN circulator could lead the team during these debriefings while the surgeon closes the surgical incision. The purposes of the debriefings were two-fold: to review team performance, including identifying any miscues and problems; and to thank team members for positive contributions. Key elements included identification of procedure delays and issues requiring follow-up, as well as assigning an overall score to the team’s performance. Compliance rates six months after implementation revealed an overall compliance rate of 95%, with 70% of individual surgeons achieving 100% compliance. Appropriate use of prophylactic antibiotics improved from 85% to 97%. A Safety Attitude Questionnaire was provided to those trained six months after implementation, with statistically significant improvement in perceptions of management and working
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conditions. Feedback from participants identified that 79% thought the program had led to improved patient safety and sense of collegiality in the OR, and 58% felt that emerging issues were better addressed with good resolutions. Data from the perioperative electronic health record provided evidence that procedures with a delayed start time decreased from 32% to 19% after medical team training. Equipment delay decreased from 24% to 6.8%. The number of issues requiring follow-up decreased from 44% to 0%. Reported hand-over issues decreased from 5.4% to 0.3%. Changes made as a result of debriefing discussions included improved equipment allocation to reduce turnaround time, modified surgeon parking arrangements to improve arrival times to the OR, improved blood gas procedures to reduce turnaround time, and improved ordering and timing of medication administration. Another study (Awad et al8) conducted in 2005 at the Baylor College of Medicine, Department of Surgery, focused on determining whether communication in the OR could be improved through medical team training. Specifically, the researchers addressed whether preoperative briefings could be used to ensure practice mandates, such as appropriate timing of prophylactic antibiotics and improved deep vein thrombosis prophylaxis. The corresponding results of implementing preoperative briefings went from 75% before medical team training to 95% after training.
TEAMSTEPPS CURRICULUM The TeamSTEPPS curriculum is the culmination of more than 25 years of research and evidence on team performance. The curriculum, which is customizable to any health care setting and contains ready-to-use video vignettes and casebased scenarios, is free and available at the AHRQ web site.2 The three outcomes as a result of successful TeamSTEPPS implementation are knowledge, attitude, and performance (Figure 1). The knowledge outcome of TeamSTEPPS is a shared mental model whereby team members have the same understanding of the situation and consistently are working toward the same goal.2 The attitude outcomes of TeamSTEPPS are mutual trust and team orientation. Typically, trust requires a shared past or experiences and is difficult to build in cultures that focus on blame rather than accountability. Following team training, personnel understand and buy into the concept of working as a team and not as an individual. An example is when team members no longer consider it “my” patient but “our” patient. This attitude and perspective is recognized by the
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Figure 1. The TeamSTEPPS triangle logo shows the four primary teamwork skills that can improve three types of teamwork outcomes. Reproduced with permission from TeamSTEPPS, Bethesda, MD. patient and is a key focus in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey question, “Did the staff work as a team?” Performance outcomes include team adaptability, accuracy, efficiency, improved productivity, and safety. As communication becomes more effective, especially through consistent use of the tools for closed-loop communication, fewer events occur that contribute to ineffective communication. This improves accuracy in care delivered, which as a result is more efficient (ie, fewer re-dos), improving productivity and patient safety. The TeamSTEPPS methodology focuses on four evidence-based teachable skills to improve team performance in situation monitoring, communication, mutual support, and leadership.2 Each of the TeamSTEPPS skills build on one another and are equally important for team success.
Situation Monitoring Situation monitoring involves actively scanning the status of the patient, team members, and the environment as the team works on the goals at hand. It may include such things as one team member recognizing that a patient’s status is deteriorating while other team members are fixing a piece of equipment and responds emergently to care for the patient.
Communication In TeamSTEPPS, communication includes using verbal strategies to improve communication between team members. The tools most often used include AORN Journal j 467
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situation, background, assessment, and recommendation (ie, SBAR); check-back; call out; or hand over. The SBAR tool provides a standardized framework for members of the health care team to communicate about a patient’s condition. On the other hand, a callout is a tool used to communicate critical information during an emergent event. A callout also can be used during a surgical procedure to communicate what actions are being taken so that team members have a common understanding of the surgeon’s or anesthesia professional’s status to prepare for next steps in the procedure. A check-back is a closed-loop communication tool to verify and validate information exchanged between team members. The Joint Commission suggests that the primary purpose of a hand over is to communicate accurate and timely information from one caregiver to another concerning the patient’s current condition, treatment, and any recent or anticipated changes.1 TeamSTEPPS provides communication tools that when used correctly will improve the way the team communicates, thus reducing preventable errors and improving patient outcomes.
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influencing others to accomplish a mission.10 Leaders may be designated because of an assignment, or they may be situational leaders whose designation can occur unexpectedly. Good leadership emphasizes the necessary skills to use the other three TeamSTEPPS skills effectively. Three tools found to facilitate good leadership and support teamwork are a briefing, huddle, and debriefing. A briefing is used at the beginning of a shift or procedure when the team discusses the objective of the work and assigns roles while establishing expectations and anticipated outcomes. In a surgery or procedure, this is called a time out. A second tool in the leadership skill arsenal is a huddle. There are many definitions of a huddle in health care, which makes it one of the most challenging tools to employ consistently. Using the correct team language is imperative for effective team communication. A huddle is when some or all of the team gather to discuss a critical event or emergency issue (eg, staffing changes, a patient fall, an emergency procedure). The third tooldthe debriefingdis a process-improvement discussion within the TeamSTEPPS framework. Team members assemble at the end of the shift or procedure to discuss what went well, what did not go well, and what could be improved on the next time.
Mutual Support Using TeamSTEPPS communication tools goes hand in hand with using the program’s next skill, mutual support. Mutual support is a core team skill and key component of the teamwork process. By using mutual support, team leaders and members recognize the risk of error that may occur when another member’s workload becomes overwhelming. Based on situation monitoring, team members take action to assist one another in the performance of their duties or shift some responsibilities to others to balance the work and provide safer patient care.
Leadership The last of the four skills, leadership, is what connects all the TeamSTEPPS skills and tools. Unfortunately, many health care education programs may not be adequately teaching the leadership skill component. Many nurses become formal leaders without leadership training. This situation can lead to failure in leadership and possibly, as a result, failure in the care being provided. Nurses may be provided management training, but management and leadership skills are not the same. Management is defined as the organization and coordination of the activities of an organization in accordance with certain policies and in achievement of clearly defined objectives.9 Leadership, on the other hand, is the process of 468 j AORN Journal
EXEMPLARS Texas Health Resources (THR) is a faith-based nonprofit health care system in North Texas, with 14 wholly owned acute-care hospitals. Texas Health Resources began implementation of TeamSTEPPS in 2009 with 10 nursing directors in leadership roles.11 The Patient Safety TeamSTEPPS observers, trained to ensure consistency, collected preimplementation data using the observation tool Teamwork Evaluation of Non-Technical Skills (TENTS).12 The areas of observation included leadership, situation monitoring, mutual support, and communication. In addition to TENTS, the observers reviewed the composite score of the communication among caregivers, patients, and families. Communication scores were based on the results from the HCAHPS. A TeamSTEPPS consultant firm provided initial training through the TeamSTEPPS Master Trainer course targeted to identify leaders (ie, champions) from each organization. Training included a two-day session in which attendees learned the tools of the program. Participants also developed action plans for implementation in their departments. Hospital action plans included education, departmental training, and plans for implementation. The goal was to develop more effective teams with improved communication and understanding. The use of
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TeamSTEPPS tools became an expectation of daily practice and workflow. Within each department, leaders supported, integrated, and managed the TeamSTEPPS processes 24 hours a day, seven days a week. Six to eight months after implementing the TeamSTEPPS tools, the Patient Safety TeamSTEPPS observers repeated their observations at each hospital, using the TENTS tool. The results were positivedmarked improvement in the TeamSTEPPS situation monitoring, communication skills, mutual support, and leadership skills were noted in eight of 10 hospitals.11 In the two facilities that did not have improvement, both were undergoing changes in leadership, making the use of the tools inconsistent, thus demonstrating the importance of leadership as realized in the TeamSTEPPS research. Texas Health Resources used the AHRQ Patient Safety Culture Survey both before and after TeamSTEPPS implementation. Eight of the 12 categories in this survey are directly affected by use of the tools. After implementation, all eight categories improved a full quartile, with some moving from the 75th percentile to the 90th percentile. The only system safety initiative during the two years between surveys was the implementation of TeamSTEPPS. Affecting the safety culture in such a short time in a large health care system was unprecedented. The greatest challenge identified by THR was physician involvement. Physicians are almost exclusively independent practitioners without employment ties to the health care system; nevertheless, success was achieved. Texas Health Resources credits the success of the project directly to committed leadership personnel who were focused on improved teamwork and communication for patient safety. “Leadership set expectations that TeamSTEPPS skills would be learned and utilized. The hospitals that were the most successful practiced the TeamSTEPPS tools on a regular basis to attain improved proficiency in their use.”11(p3) The Veterans Health Administration is the largest national health care system in the United States, with 153 hospitals. The Veterans Health Administration implemented a team training program to determine whether there is an association between team training and surgical outcomes.13 The nationwide training program required briefings and debriefings in the OR and included checklists as a mandated process. Training included two months of preparation, a one-day conference, and a year of quarterly coaching reviews. Team members were trained to challenge each other in identifying safety risks, conducting checklist-guided briefings preoperatively, and conducting postoperative debriefings.
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Table 1. Organizational Success Factors
1
Supportive organizational culture and learning climate Shared vision (ie, leadership to front line) Visible leadership support Peer and subordinate support Reinforcement, rewards, and recognition Minimal delay between training and practice on the job Ongoing training (eg, coaching, refresher, new personnel) Commitment to measurement and ongoing improvement Sustainment plan Resource availability Physician engagement Accountability
1. TeamSTEPPS: Implementation Guide. AHRQ. http://www.ahrq .gov/professionals/education/curriculum-tools/teamstepps/ instructor/essentials/implguide.pdf. Accessed December 19, 2014.
Teams were taught to implement communication strategies such as
recognizing red flags, knowing the rules of conduct for communication, stepping back and reassessing a situation, and providing effective communication during patient hand offs to other caregivers.
A retrospective study, inclusive of a control group, validated that participating in the Veterans Health Administration medical team training program was associated with lower surgical mortality. The analysis included 182,409 sampled procedures from 108 facilities. The 74 facilities in the training program experienced an 18% reduction in annual mortality, compared with a 7% decrease among the 34 facilities that had not undergone training.13 Researchers hypothesized that conducting the preoperative briefings is a key component in reducing mortality. The briefings require active participation and involvement of team members and provide a final chance to correct problems before starting the procedure.
Go-To Resources Guidance for implementation can be found as an open resource on the AHRQ web sites: TeamSTEPPS: National Implementation (AHRQ) and TeamSTEPPS Implementation Guide (AHRQ).14 Curricula available include assessments, tools, training videos, and continuing education.14 Should additional discussion be needed for “lessons learned” from TeamSTEPPS implementation and sustainment, you may contact the THR authors of this column. AORN Journal j 469
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CONCLUSION Evidence shows that implementation of TeamSTEPPS in surgical settings has resulted in achieving organizational success factors, thus reducing error and patient harm (Table 1). TeamSTEPPS is basically a three-step process that involves pretraining assessment, followed by training for on-site trainers and personnel and then implementation and sustainment of the program. The goals of the program are to create and maintain a culture of safety by changing team behavior. The behavior change requires team members to share the same mental model of goals to be accomplished. Within surgical services, the role of the OR leader is to ignite, change, and shift the culture to higher levels of performance and safe care. The effects of nursing administrators and managers who demonstrate strong leadership skills cannot be understated. Leadership is the glue that connects the concepts and elements required for successful implementation of TeamSTEPPS.
Editor’s note: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD.
References 1. Facts about the hand-off communications project. Joint Commission Center for Transforming Healthcare. http://www.centerfor transforminghealthcare.org/assets/4/6/CTH_HOC_Fact_Sheet.pdf. Accessed December 19, 2014. 2. King HB, Battles J, Baker DP, et al. TeamSTEPPS: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles J, Keyes MA, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www .ahrq.gov/downloads/pub/advances2/vol3/advances-king_1.pdf. Accessed December 18, 2014. 3. Marshall D. The History of Crew Resource Management: From Patient Safety to High Reliability. Centennial, CO: Safer Healthcare; 2010. 4. Leonard M, Graham S, Bonacam D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-i90. 5. Kohn L, Corrigan J, Donaldson M, et al. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 1999. 6. Salas E, Almedia SA, Salisbury M, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf. 2009;35(8):398-405.
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7. Wolf FA, Way LW, Steward L. The efficiency of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4,863 cases. Ann Surg. 2010; 252(3):477-483. 8. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-774. 9. Define management and its functions. Management Innovations. http://managementinnovations.wordpress.com/2008/12/03/define -management-its-functions/. Accessed December 19, 2014. 10. Leadership. Army Study Guide. http://www.armystudyguide.com/ content/army_board_study_guide_topics/leadership/leadership -study-guide.shtml. Accessed December 19, 2014. 11. Sheppard F, Williams M, Klein VR. TeamSTEPPS and patient safety in healthcare. J Healthc Risk Manag. 2013;32(3):5-10. 12. Hohenhaus S, Powell S, Haskins R. A practical approach to observation in the emergency care setting. J Emerg Nurs. 2008; 34(2):142-144. 13. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. 14. TeamSTEPPS: Implementation Guide. AHRQ. http://www.ahrq.gov/ professionals/education/curriculum-tools/teamstepps/instructor/ essentials/implguide.pdf. Accessed on December 19, 2014.
Cynthia Plonien, DNP, RN, CENP is the director of the Graduate Program of Nursing Administration and a clinical assistant professor for the University of Texas at Arlington College of Nursing. Dr Plonien has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Marcie Williams, MS, RN, FASHRM, CPHRM is a senior director of Enterprise Risk Management for Texas Health Resources, Arlington, TX. Ms Williams has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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Stepping Up Teamwork via TeamSTEPPS CYNTHIA PLONIEN, DNP, RN, CENP; MARCIE WILLIAMS, MS, RN, FASHRM, CPHRM
P
erioperative leaders are in the spotlight to develop and manage effective and safe teams caring for patients in the OR setting. Leadership does not begin and end with personnel reporting to nurse managers. It must involve every member of the OR team with a connection to the patient during a surgical procedure, inclusive of physicians and vendors. The OR is a complex environment in which effective communication and the coordination of multiple team members can be critical for safe and efficient functioning. Team members rely on one another’s expertise for completing tasks successfully. They must share information rapidly when responding to expected and unexpected events. Mistakes in communication are cited by The Joint Commission as the principle underlying cause of human error.1 Improved teamwork and communication have been identified as a priority by The Joint Commission and Agency for Healthcare Research and Quality (AHRQ).1,2
been developed by the AHRQ and the Department of Defense to improve quality and safety in health care.2 The TeamSTEPPS tool is an open resource that is available and free of charge for administrators and managers. Implementation of new processes that require a change in behavior is seldom easy. However, numerous organizations have been very successful in using TeamSTEPPS as an evidence-based method to enhance clinical communication within teams and improve patient outcomes in the OR. The focus of this column is an overview of TeamSTEPPS, inclusive of recommendations for successful implementation by OR executives and leaders who are intent on increasing safety as well as efficiency in the OR setting by improving team performance.
Teamwork tools, such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), have
TeamSTEPPS had its beginnings with crew resource management (CRM), a set of training procedures incorporated into
EVOLUTION OF TEAMSTEPPS
http://dx.doi.org/10.1016/j.aorn.2015.01.006 ª AORN, Inc, 2015
www.aornjournal.org
AORN Journal j 465
PloniendWilliams
a 1973 National Aeronautics and Space Administration workshop designed to increase air travel safety and reduce fatal accidents attributed to human error.3 Aviation disasters of the 1970s triggered an innovative shift from errors attributed to mechanical failure or pilot training to errors attributed to communication to prevention of error through CRM and improved team communication. At that time, studies had identified the primary cause of fatal airline accidents as human error.3,4 Specifically, the cause was found to be failures in the cockpit related to communication, leadership, and decision making. Further study of airline accidents identified that 70% of commercial airline accidents were attributed to communication errors.4 For example, in 1977, an incident occurred when two Boeing 747s collided on a runway with another, and 582 lives were lost. One of the pilots mistakenly thought the preflight checklist had been completed and attempted take off without clearance. The tragedy traced back to human error. The critical nature of communication in aviation with resulting error is similar to outcomes that have been observed in health care. A high rate of human error with disastrous results to quality also occurs in health care. Public awareness of health care quality reached a critical mass after publication of the 1999 Institute of Medicine report, To Err Is Human: Building a Safer Health System.5 The report concluded that medical errors result in an estimated 98,000 preventable deaths annually.5 Subsequent to the report, evidence-based research, as well as governmental and accreditation organizations, has cited the importance of teamwork and communication in patient safety.
OR TEAMS It is of no surprise to OR leaders that effective communication and teamwork are essential for safe care and avoidance of error resulting in harm. Teams can be defined as a group that share a cognitive common ground and solve unique problems by coordinated action, often in a dynamic setting where protocols and checklists are not applicable.6(p398) Teamwork, in this sense, is a critical aspect of patient care in the OR.6 Historically, quality and safety leadership was left to the expert practitioner, the surgeon. However, as evidence has shown, teams make better decisions than do individuals. In regard to safety, the surgeon is no longer the “captain of the ship.” Today’s ORs consist of countless individuals working together to perform high-risk tasks, and each member of the team has a responsibility to protect the patient. In ensuring safety, an OR leader is supported by standardized tools and an environment in which individuals can speak up to share concerns and alert members of the team to unsafe 466 j AORN Journal
April 2015, Volume 101, No. 4
conditions. The TeamSTEPPS methodology employs a common language in communication together with associated protocols proved to result in improved patient safety outcomes.
RESEARCH Considerable research has been published regarding the improvements realized after medical team training. In the perioperative environment, two specific TeamSTEPPS toolsdbriefings and debriefingsdseem to provide the most benefit in improving effective communication among OR team members and improving the actual operations of the department. One of the largest published research projects related to the application of briefings and debriefings after medical team training is an analysis of 4,863 cases.7 After OR team training with surgeons, anesthesia professionals, and perioperative personnel, preoperative briefings were conducted in the OR before the incision was made. The project was led by the surgeons, with opportunities for all team members to provide input. To encourage speaking up, the surgeon asked if anyone had any concerns; this is a new approach used in the OR setting, which is known for its strict hierarchical environment. The purpose of the project was for the entire team to understand the following key performance goals: ensure that preoperative preparation is complete and focuses on site-specific needs, identify critical steps for possible complications, and promote communication and teamwork throughout the procedure. In addition, postoperative debriefings were conducted after the surgical procedures were completed but before the team left the OR. The RN circulator could lead the team during these debriefings while the surgeon closes the surgical incision. The purposes of the debriefings were two-fold: to review team performance, including identifying any miscues and problems; and to thank team members for positive contributions. Key elements included identification of procedure delays and issues requiring follow-up, as well as assigning an overall score to the team’s performance. Compliance rates six months after implementation revealed an overall compliance rate of 95%, with 70% of individual surgeons achieving 100% compliance. Appropriate use of prophylactic antibiotics improved from 85% to 97%. A Safety Attitude Questionnaire was provided to those trained six months after implementation, with statistically significant improvement in perceptions of management and working
www.aornjournal.org
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Teamwork via TeamSTEPPS
conditions. Feedback from participants identified that 79% thought the program had led to improved patient safety and sense of collegiality in the OR, and 58% felt that emerging issues were better addressed with good resolutions. Data from the perioperative electronic health record provided evidence that procedures with a delayed start time decreased from 32% to 19% after medical team training. Equipment delay decreased from 24% to 6.8%. The number of issues requiring follow-up decreased from 44% to 0%. Reported hand-over issues decreased from 5.4% to 0.3%. Changes made as a result of debriefing discussions included improved equipment allocation to reduce turnaround time, modified surgeon parking arrangements to improve arrival times to the OR, improved blood gas procedures to reduce turnaround time, and improved ordering and timing of medication administration. Another study (Awad et al8) conducted in 2005 at the Baylor College of Medicine, Department of Surgery, focused on determining whether communication in the OR could be improved through medical team training. Specifically, the researchers addressed whether preoperative briefings could be used to ensure practice mandates, such as appropriate timing of prophylactic antibiotics and improved deep vein thrombosis prophylaxis. The corresponding results of implementing preoperative briefings went from 75% before medical team training to 95% after training.
TEAMSTEPPS CURRICULUM The TeamSTEPPS curriculum is the culmination of more than 25 years of research and evidence on team performance. The curriculum, which is customizable to any health care setting and contains ready-to-use video vignettes and casebased scenarios, is free and available at the AHRQ web site.2 The three outcomes as a result of successful TeamSTEPPS implementation are knowledge, attitude, and performance (Figure 1). The knowledge outcome of TeamSTEPPS is a shared mental model whereby team members have the same understanding of the situation and consistently are working toward the same goal.2 The attitude outcomes of TeamSTEPPS are mutual trust and team orientation. Typically, trust requires a shared past or experiences and is difficult to build in cultures that focus on blame rather than accountability. Following team training, personnel understand and buy into the concept of working as a team and not as an individual. An example is when team members no longer consider it “my” patient but “our” patient. This attitude and perspective is recognized by the
www.aornjournal.org
Figure 1. The TeamSTEPPS triangle logo shows the four primary teamwork skills that can improve three types of teamwork outcomes. Reproduced with permission from TeamSTEPPS, Bethesda, MD. patient and is a key focus in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey question, “Did the staff work as a team?” Performance outcomes include team adaptability, accuracy, efficiency, improved productivity, and safety. As communication becomes more effective, especially through consistent use of the tools for closed-loop communication, fewer events occur that contribute to ineffective communication. This improves accuracy in care delivered, which as a result is more efficient (ie, fewer re-dos), improving productivity and patient safety. The TeamSTEPPS methodology focuses on four evidence-based teachable skills to improve team performance in situation monitoring, communication, mutual support, and leadership.2 Each of the TeamSTEPPS skills build on one another and are equally important for team success.
Situation Monitoring Situation monitoring involves actively scanning the status of the patient, team members, and the environment as the team works on the goals at hand. It may include such things as one team member recognizing that a patient’s status is deteriorating while other team members are fixing a piece of equipment and responds emergently to care for the patient.
Communication In TeamSTEPPS, communication includes using verbal strategies to improve communication between team members. The tools most often used include AORN Journal j 467
PloniendWilliams
situation, background, assessment, and recommendation (ie, SBAR); check-back; call out; or hand over. The SBAR tool provides a standardized framework for members of the health care team to communicate about a patient’s condition. On the other hand, a callout is a tool used to communicate critical information during an emergent event. A callout also can be used during a surgical procedure to communicate what actions are being taken so that team members have a common understanding of the surgeon’s or anesthesia professional’s status to prepare for next steps in the procedure. A check-back is a closed-loop communication tool to verify and validate information exchanged between team members. The Joint Commission suggests that the primary purpose of a hand over is to communicate accurate and timely information from one caregiver to another concerning the patient’s current condition, treatment, and any recent or anticipated changes.1 TeamSTEPPS provides communication tools that when used correctly will improve the way the team communicates, thus reducing preventable errors and improving patient outcomes.
April 2015, Volume 101, No. 4
influencing others to accomplish a mission.10 Leaders may be designated because of an assignment, or they may be situational leaders whose designation can occur unexpectedly. Good leadership emphasizes the necessary skills to use the other three TeamSTEPPS skills effectively. Three tools found to facilitate good leadership and support teamwork are a briefing, huddle, and debriefing. A briefing is used at the beginning of a shift or procedure when the team discusses the objective of the work and assigns roles while establishing expectations and anticipated outcomes. In a surgery or procedure, this is called a time out. A second tool in the leadership skill arsenal is a huddle. There are many definitions of a huddle in health care, which makes it one of the most challenging tools to employ consistently. Using the correct team language is imperative for effective team communication. A huddle is when some or all of the team gather to discuss a critical event or emergency issue (eg, staffing changes, a patient fall, an emergency procedure). The third tooldthe debriefingdis a process-improvement discussion within the TeamSTEPPS framework. Team members assemble at the end of the shift or procedure to discuss what went well, what did not go well, and what could be improved on the next time.
Mutual Support Using TeamSTEPPS communication tools goes hand in hand with using the program’s next skill, mutual support. Mutual support is a core team skill and key component of the teamwork process. By using mutual support, team leaders and members recognize the risk of error that may occur when another member’s workload becomes overwhelming. Based on situation monitoring, team members take action to assist one another in the performance of their duties or shift some responsibilities to others to balance the work and provide safer patient care.
Leadership The last of the four skills, leadership, is what connects all the TeamSTEPPS skills and tools. Unfortunately, many health care education programs may not be adequately teaching the leadership skill component. Many nurses become formal leaders without leadership training. This situation can lead to failure in leadership and possibly, as a result, failure in the care being provided. Nurses may be provided management training, but management and leadership skills are not the same. Management is defined as the organization and coordination of the activities of an organization in accordance with certain policies and in achievement of clearly defined objectives.9 Leadership, on the other hand, is the process of 468 j AORN Journal
EXEMPLARS Texas Health Resources (THR) is a faith-based nonprofit health care system in North Texas, with 14 wholly owned acute-care hospitals. Texas Health Resources began implementation of TeamSTEPPS in 2009 with 10 nursing directors in leadership roles.11 The Patient Safety TeamSTEPPS observers, trained to ensure consistency, collected preimplementation data using the observation tool Teamwork Evaluation of Non-Technical Skills (TENTS).12 The areas of observation included leadership, situation monitoring, mutual support, and communication. In addition to TENTS, the observers reviewed the composite score of the communication among caregivers, patients, and families. Communication scores were based on the results from the HCAHPS. A TeamSTEPPS consultant firm provided initial training through the TeamSTEPPS Master Trainer course targeted to identify leaders (ie, champions) from each organization. Training included a two-day session in which attendees learned the tools of the program. Participants also developed action plans for implementation in their departments. Hospital action plans included education, departmental training, and plans for implementation. The goal was to develop more effective teams with improved communication and understanding. The use of
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Teamwork via TeamSTEPPS
TeamSTEPPS tools became an expectation of daily practice and workflow. Within each department, leaders supported, integrated, and managed the TeamSTEPPS processes 24 hours a day, seven days a week. Six to eight months after implementing the TeamSTEPPS tools, the Patient Safety TeamSTEPPS observers repeated their observations at each hospital, using the TENTS tool. The results were positivedmarked improvement in the TeamSTEPPS situation monitoring, communication skills, mutual support, and leadership skills were noted in eight of 10 hospitals.11 In the two facilities that did not have improvement, both were undergoing changes in leadership, making the use of the tools inconsistent, thus demonstrating the importance of leadership as realized in the TeamSTEPPS research. Texas Health Resources used the AHRQ Patient Safety Culture Survey both before and after TeamSTEPPS implementation. Eight of the 12 categories in this survey are directly affected by use of the tools. After implementation, all eight categories improved a full quartile, with some moving from the 75th percentile to the 90th percentile. The only system safety initiative during the two years between surveys was the implementation of TeamSTEPPS. Affecting the safety culture in such a short time in a large health care system was unprecedented. The greatest challenge identified by THR was physician involvement. Physicians are almost exclusively independent practitioners without employment ties to the health care system; nevertheless, success was achieved. Texas Health Resources credits the success of the project directly to committed leadership personnel who were focused on improved teamwork and communication for patient safety. “Leadership set expectations that TeamSTEPPS skills would be learned and utilized. The hospitals that were the most successful practiced the TeamSTEPPS tools on a regular basis to attain improved proficiency in their use.”11(p3) The Veterans Health Administration is the largest national health care system in the United States, with 153 hospitals. The Veterans Health Administration implemented a team training program to determine whether there is an association between team training and surgical outcomes.13 The nationwide training program required briefings and debriefings in the OR and included checklists as a mandated process. Training included two months of preparation, a one-day conference, and a year of quarterly coaching reviews. Team members were trained to challenge each other in identifying safety risks, conducting checklist-guided briefings preoperatively, and conducting postoperative debriefings.
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Table 1. Organizational Success Factors
1
Supportive organizational culture and learning climate Shared vision (ie, leadership to front line) Visible leadership support Peer and subordinate support Reinforcement, rewards, and recognition Minimal delay between training and practice on the job Ongoing training (eg, coaching, refresher, new personnel) Commitment to measurement and ongoing improvement Sustainment plan Resource availability Physician engagement Accountability
1. TeamSTEPPS: Implementation Guide. AHRQ. http://www.ahrq .gov/professionals/education/curriculum-tools/teamstepps/ instructor/essentials/implguide.pdf. Accessed December 19, 2014.
Teams were taught to implement communication strategies such as
recognizing red flags, knowing the rules of conduct for communication, stepping back and reassessing a situation, and providing effective communication during patient hand offs to other caregivers.
A retrospective study, inclusive of a control group, validated that participating in the Veterans Health Administration medical team training program was associated with lower surgical mortality. The analysis included 182,409 sampled procedures from 108 facilities. The 74 facilities in the training program experienced an 18% reduction in annual mortality, compared with a 7% decrease among the 34 facilities that had not undergone training.13 Researchers hypothesized that conducting the preoperative briefings is a key component in reducing mortality. The briefings require active participation and involvement of team members and provide a final chance to correct problems before starting the procedure.
Go-To Resources Guidance for implementation can be found as an open resource on the AHRQ web sites: TeamSTEPPS: National Implementation (AHRQ) and TeamSTEPPS Implementation Guide (AHRQ).14 Curricula available include assessments, tools, training videos, and continuing education.14 Should additional discussion be needed for “lessons learned” from TeamSTEPPS implementation and sustainment, you may contact the THR authors of this column. AORN Journal j 469
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CONCLUSION Evidence shows that implementation of TeamSTEPPS in surgical settings has resulted in achieving organizational success factors, thus reducing error and patient harm (Table 1). TeamSTEPPS is basically a three-step process that involves pretraining assessment, followed by training for on-site trainers and personnel and then implementation and sustainment of the program. The goals of the program are to create and maintain a culture of safety by changing team behavior. The behavior change requires team members to share the same mental model of goals to be accomplished. Within surgical services, the role of the OR leader is to ignite, change, and shift the culture to higher levels of performance and safe care. The effects of nursing administrators and managers who demonstrate strong leadership skills cannot be understated. Leadership is the glue that connects the concepts and elements required for successful implementation of TeamSTEPPS.
Editor’s note: TeamSTEPPS is a registered trademark of the US Department of Defense, Falls Church, VA, and the US Department of Health and Human Services, Bethesda, MD.
References 1. Facts about the hand-off communications project. Joint Commission Center for Transforming Healthcare. http://www.centerfor transforminghealthcare.org/assets/4/6/CTH_HOC_Fact_Sheet.pdf. Accessed December 19, 2014. 2. King HB, Battles J, Baker DP, et al. TeamSTEPPS: team strategies and tools to enhance performance and patient safety. In: Henriksen K, Battles J, Keyes MA, et al., eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www .ahrq.gov/downloads/pub/advances2/vol3/advances-king_1.pdf. Accessed December 18, 2014. 3. Marshall D. The History of Crew Resource Management: From Patient Safety to High Reliability. Centennial, CO: Safer Healthcare; 2010. 4. Leonard M, Graham S, Bonacam D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-i90. 5. Kohn L, Corrigan J, Donaldson M, et al. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 1999. 6. Salas E, Almedia SA, Salisbury M, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf. 2009;35(8):398-405.
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7. Wolf FA, Way LW, Steward L. The efficiency of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4,863 cases. Ann Surg. 2010; 252(3):477-483. 8. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-774. 9. Define management and its functions. Management Innovations. http://managementinnovations.wordpress.com/2008/12/03/define -management-its-functions/. Accessed December 19, 2014. 10. Leadership. Army Study Guide. http://www.armystudyguide.com/ content/army_board_study_guide_topics/leadership/leadership -study-guide.shtml. Accessed December 19, 2014. 11. Sheppard F, Williams M, Klein VR. TeamSTEPPS and patient safety in healthcare. J Healthc Risk Manag. 2013;32(3):5-10. 12. Hohenhaus S, Powell S, Haskins R. A practical approach to observation in the emergency care setting. J Emerg Nurs. 2008; 34(2):142-144. 13. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. 14. TeamSTEPPS: Implementation Guide. AHRQ. http://www.ahrq.gov/ professionals/education/curriculum-tools/teamstepps/instructor/ essentials/implguide.pdf. Accessed on December 19, 2014.
Cynthia Plonien, DNP, RN, CENP is the director of the Graduate Program of Nursing Administration and a clinical assistant professor for the University of Texas at Arlington College of Nursing. Dr Plonien has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Marcie Williams, MS, RN, FASHRM, CPHRM is a senior director of Enterprise Risk Management for Texas Health Resources, Arlington, TX. Ms Williams has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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