teamwork training & crm

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Multidisciplinary Teamwork Training: Multidisciplinary Teamwork Training: In the Classroom & with SimulationIn the Classroom & with Simulation

Diane Sliwka, MDNiraj L. Sehgal, MD, MPH

Division of Hospital MedicineUniversity of California, San Francisco

Welcome!Welcome!

Who are you?

Why are you here?

What do you want to learn?

Why are you here?Why are you here?

Leading a program at your institutionLeading a program at your institution

Looking for new ways to promote improved Looking for new ways to promote improved communication and teamwork communication and teamwork

Skeptical about the utility (need convincing)Skeptical about the utility (need convincing)

You know itYou know it’’s the s the ‘‘right thing to doright thing to do’’ and need to and need to convince someone elseconvince someone else……

What do you want to learn?What do you want to learn?

Context and driving forces for teamwork trainingContext and driving forces for teamwork training

ClassroomClassroom--based Instructionbased Instruction

SimulationSimulation--based instructionbased instruction

Q&A: Point & CounterpointQ&A: Point & Counterpoint

Teamwork Training & CRMTeamwork Training & CRM

Primarily out of aviation and the militaryComplex environmentsCommunication across disciplinesCritical information communicated efficientlyUrgent/emergent situations

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Aviation AccidentsAviation Accidents((per Million Departures)per Million Departures)

Systems

CULTURE!

The Aviation DisconnectThe Aviation Disconnect

Medical Progress Over Medical Progress Over Half a CenturyHalf a Century

Nurses Pharmacists

Physicians

PT & OT

CM & SW Unit service coordinator

Patient

Context for Teamwork TrainingContext for Teamwork Training[Complexity of Inpatient Care][Complexity of Inpatient Care]

RTPCA

We train, learn, and work in silos…

Nutrition

How good are we at How good are we at communicating and communicating and

teamwork?teamwork?

JCAHO

3

0%

10%

20%

30%

40%

50%

60%

70%

80%

Attending SurgeonsAnesthesiologistsSurgical NursesAnesthesia NursesAnesthesia Residents

Perceptions of Teamwork Perceptions of Teamwork ““HighHigh””

Sexton, British Medical Journal, 2000

0%

10%

20%

30%

40%

50%

SurgeonsPilots

Decisions of the Decisions of the ““leaderleader””should should not not be questionedbe questioned

Sexton, British Medical Journal, 2000

Barriers to TeamworkBarriers to Teamwork

Lack of timeLack of timeLack of information sharingLack of information sharingHierarchyHierarchyDefensivenessDefensivenessVarying communication stylesVarying communication stylesDistractionsDistractionsFatigueFatigueWorkloadWorkloadLack of role clarityLack of role clarity

Drivers for Teamwork TrainingDrivers for Teamwork Training

The The ““right thing to doright thing to do””

JCAHOJCAHOcommunication & signcommunication & sign--outsouts

Drivers for Teamwork TrainingDrivers for Teamwork Training

The The ““right thing to doright thing to do””

JCAHOJCAHOcommunication & signcommunication & sign--outsouts

ACGME competenciesACGME competenciesSystemSystem--based practicebased practicePracticePractice--based learning improvementbased learning improvement

Patient SafetyPatient Safety

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How do we teach it?How do we teach it?GOAL:GOAL:1) Teach Knowledge, Skills, and Attitudes1) Teach Knowledge, Skills, and Attitudes2) Transfer above into clinical setting and 2) Transfer above into clinical setting and

improve patient care and safetyimprove patient care and safety

ClassroomClassroom--based instruction vs. Simulation ???based instruction vs. Simulation ???





Q & A: Point & CounterpointQ & A: Point & Counterpoint

Evidence mixed but Evidence mixed but ‘‘outcomeoutcome’’ variably definedvariably definedER, OR & ICU settingsER, OR & ICU settings------all MULTIDISCIPLINARY!all MULTIDISCIPLINARY!Outside Consultants (CRM)Outside Consultants (CRM)Benefits via improved Benefits via improved ‘‘safety culturesafety culture’’

Focus on:Focus on:Improved proceduresImproved proceduresStandardized communication toolsStandardized communication toolsDampen down hierarchiesDampen down hierarchies

National Patient Safety Goal?National Patient Safety Goal?

ClassroomClassroom--Based Based Teamwork TrainingTeamwork Training What do we teach?What do we teach?

Teamwork PrinciplesFlattening hierarchy, Defining the Team

Communication ToolsSBAR, CUS words

Operational/Practical InterventionsCritical Conversations, Text paging

Hierarchy: Vertical and HorizontalHierarchy: Vertical and Horizontal

MD HierarchyMedical student (MS 3)Sub-Intern (MS 4)Intern (PGY-1)Resident (PGY-2/3)Chief Resident (PGY-4)Attending (PGY…)

Nursing HierarchyPatient care asst.Bedside nurseSenior nursesCharge nurseNursing manager

Unwritten code of conduct and influenced by tradition, stereotyping, gender, age, etc…

Broadly impacts communication, teamwork, patient care

“If you see something going wrong, I want you to say something”

Defining the Healthcare Defining the Healthcare ““TeamTeam””

The Medical TeamAttendingResidentIntern(s)Student(s)

The Team Caring for the PatientPatient care asst.Bedside nurseRespiratory TherapyPhysical TherapyPharmacistNutritionTransportLift TeamCase managerSocial WorkerPhysicians

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Communication and TeamworkCommunication and Teamwork




SSBBAARR

SBAR is a tool SBAR is a tool for urgent for urgent

communicationcommunicationituationituation

ackgroundackground

ssessmentssessment

ecommendationecommendation

SSBBAARR

ituationituationGet the persons attention quickly. Identify the patient and Get the persons attention quickly. Identify the patient and yourself and your reason for calling. (5yourself and your reason for calling. (5--10 seconds) 10 seconds)

What you want them to do, why, when? What you want them to do, why, when? ▲▲ Informational call:Informational call:““by the wayby the way……▲▲ Request for action: Request for action: ““II’’dd like an order forlike an order for…”…”▲▲Emergent call:Emergent call: ““I need you to comeI need you to come now...now...””

ecommendationecommendation

ackgroundackground

ssessmentssessmentTell them what you think is going onTell them what you think is going on

Give pertinent background informationGive pertinent background information

SBAR as a Communication ToolSBAR as a Communication Tool

Designed as an RN-MD toolCan be extrapolated to other interactionsNot for every communication

Colace for constipationNon-formulary request form

Tool for urgent/emergent situationsSuccess requires broad training

RN, MD, others

CCUUSS

CUS words CUS words standardize the standardize the

language of language of urgencyurgencyoncernedoncerned

ncomfortablencomfortable

afetyafety IssueIssue

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SSBBAARR

I’m Paul the nurse from 7 south. Mrs. Smith in 742 is in respiratory distressII’’m Paul the nurse from 7 south. Mrs. m Paul the nurse from 7 south. Mrs. Smith in 742 is in respiratory distressSmith in 742 is in respiratory distress

She has severe COPD, has been doing poorly all day, and is now worse.She has severe COPD, has been doing She has severe COPD, has been doing poorly all day, and is now worse.poorly all day, and is now worse.

Her breath sounds are diminished. She’s not moving much air. I think she needs a treatment before she stops breathing.

Her breath sounds are diminished. Her breath sounds are diminished. SheShe’’s not moving much air. I think she s not moving much air. I think she needs a treatment before she stops needs a treatment before she stops breathing. breathing.

I’m concerned and I’d like you to come and evaluate her immediately.II’’m m concernedconcerned and Iand I’’d like you to come d like you to come and evaluate her immediately.and evaluate her immediately.

Communication and TeamworkCommunication and Teamwork




Critical ConversationsCritical Conversations

Times at which face-to-face or verbal conversations about patients are essentialClarify the plan of careOpportunity to ask questions

Text Paging CommunicationText Paging Communication

Achieved institutional support to upgrade pager system.

Worked with nursing leadership, did in-service with nursing units

Standardized the format of text messaging

Clear indication of who you are pagingClear indication of who you are pagingClear indication of the patient &Clear indication of the patient &

description of the issuedescription of the issue

Your name, title, location, the callback #Your name, title, location, the callback #

If you need a callback or not (must)If you need a callback or not (must)

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TTriad for riad for OOptimal ptimal PPatient atient SSafetyafety(TOPS)(TOPS)

School of Nursing

School of Medicine

School of Pharmacy

TOPS 4hr Training AgendaTOPS 4hr Training Agenda

Typical Program:8-8:20a: Laying the Foundation8:20-9:00a: “Do No Harm” Video Presentation

Facilitated Discussion9:00-10:00a: Healthcare Team Training Skills Lecture10:15-11:45a: Two Small Group Scenarios

Facilitated Sessions11:45-12p: Wrap-up and Evaluation…

TOPS Training OverviewTOPS Training Overview

22

90

22

7

15 24

152

ResidentsAttendingsNursesPharmacistsCase ManagersRT/PT/OTOther Staff

325 ‘TOPS Trained’99% of the Nurses

75% of Docs

1000% of Pharmacists

* 99% rec’d training to colleagues* Biggest obstacle: Time & Workload4.6

4.7

4.4

4.3

0 1 2 3 4 5

"Training will change my practice"

Overall Rating of Training Session

Use of a Multidisciplinary Setting for Training

"Training will change the way I communicate"

TOPS TrainingTOPS TrainingSuccess StoriesSuccess Stories

Power of Power of ““getting everyone in the same roomgetting everyone in the same room””Degree of engagement across disciplinesDegree of engagement across disciplinesGreat Great anecdotes and storiesanecdotes and stories from participants from participants both during and after the trainingboth during and after the trainingCombining didactic, small group, and videoCombining didactic, small group, and video……

TOPS TrainingTOPS TrainingLessons & Take Home PointsLessons & Take Home Points

1.1. Multidisciplinary planning/participation is keyMultidisciplinary planning/participation is key

2.2. Logistics drive the trainingLogistics drive the training——time, place, and scheduling of time, place, and scheduling of participants who work different shifts, days, and hours into participants who work different shifts, days, and hours into the same the same ‘‘educational spaceeducational space’’

3.3. Educational activities need to be coupled with operational Educational activities need to be coupled with operational initiativesinitiatives

4.4. Need to create further opportunities for skills training and Need to create further opportunities for skills training and conferences as this canconferences as this can’’t be a t be a ““one and doneone and done”” training training sessionsession

5.5. QI: learn from failure as much as successQI: learn from failure as much as success

Additional Educational ActivitiesAdditional Educational Activities

Quarterly Patient Safety ConferencesLarge-group and multidisciplinary audienceCase-based “M & M”-type presentationBuild on principles from initial 4hr Training

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How can I start this Monday?How can I start this Monday?

Choose your level of ambition (time and logistics)Laying the Foundation

“Do No Harm” Video Presentation and DiscussionHealthcare Team Training SkillsFacilitated Small Group Scenario Discussion

Wrap-up and Closing Thoughts…-------------------------------------------------------------------

1hr sessions: Ready to go... 2hr sessions: some planning and partnerships4hr sessions: have administrative support!






Simulation in Team Simulation in Team TrainingTraining

BeyondBeyond““See One, Do One, Teach See One, Do One, Teach

OneOne””

OutlineOutline

I. What is Simulation?I. What is Simulation?II. Current EvidenceII. Current Evidence

III. Skills to Teach Teams Using SimulationIII. Skills to Teach Teams Using Simulation

What is Simulation?What is Simulation?

Diane.wmv

SimulationSimulation(It(It’’s a technique, not a technology.)s a technique, not a technology.)

Low FidelityLow FidelityRole Play Role Play Screen based Screen based Partial task trainers Partial task trainers

High FidelityHigh FidelityComputer driven full Computer driven full body mannequinsbody mannequins

come to lifecome to lifetalk to traineestalk to traineestrue physiologytrue physiologyrealistic environmentrealistic environment

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Behind the One Way MirrorBehind the One Way Mirror PrinciplesPrinciples

Adult Learning TheoryAdult Learning TheoryActivated Learning Activated Learning Performance (Integrating skills)Performance (Integrating skills)PracticePracticeHigh stakes/rare clinical scenariosHigh stakes/rare clinical scenariosReproducibilityReproducibilityControlled EnvironmentControlled Environment

Affect and LearningAffect and Learning

ACTIVATION

DEACTIVATION

PLEASANTUNPLEASANT

Tense Nervous

Stressed Upset

Alert Excited

Elated Happy

Sad Depressed

Bored

Russell, 2003

Contented Serene

Relaxed Calm

How Simulation Impacts Learning:How Simulation Impacts Learning:TheoryTheory

Surprise/ vulnerabilitySurprise/ vulnerabilityYou donYou don’’t know what you thought you knewt know what you thought you knew

MotivationMotivationStimulus to learnStimulus to learn

Reinforcement (with psychological safety)Reinforcement (with psychological safety)Debriefing by expertsDebriefing by experts

Current Evidence (1)Current Evidence (1)

Educational MeasuresEducational MeasuresTask Performance/Technical Skill TrainingTask Performance/Technical Skill TrainingTeamworkTeamworkMost effective learning: Most effective learning: feedback,feedback, repetitive repetitive practice, curriculum integrationpractice, curriculum integration

Current Evidence (2)Current Evidence (2)

Translation to Clinical Care: Translation to Clinical Care: Trainee Performance in clinical settingTrainee Performance in clinical settingPatient OutcomesPatient Outcomes

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How To Get StartedHow To Get StartedGain Gain ““Buy InBuy In”” from Stake Holdersfrom Stake Holders

Hospital mission, safety goals, ACGME requirements, Hospital mission, safety goals, ACGME requirements, research agenda, faculty training goals, medical research agenda, faculty training goals, medical errorserrors------make your agenda their agendamake your agenda their agenda

Physician Champions/Thought LeadersPhysician Champions/Thought LeadersInvest in Faculty (interdisciplinary) Invest in Faculty (interdisciplinary) Needs assessmentNeeds assessmentComplement (rather than replace) existing Complement (rather than replace) existing effortseffortsSetting: close proximity to patient care areasSetting: close proximity to patient care areasEvaluate/Assess impactEvaluate/Assess impact

Ideas: Where To Get ThemIdeas: Where To Get ThemHospitalist Hospitalist M&MsM&MsObserve codes/ rapid response teamsObserve codes/ rapid response teamsQuality Improvement ConferencesQuality Improvement ConferencesIncident Reports/ Sentinel EventsIncident Reports/ Sentinel EventsSimulations provide assessment opportunitiesSimulations provide assessment opportunities

Keep It SimpleKeep It Simple

Team Training SkillsTeam Training SkillsSBARSBARClosed Loop Communication Closed Loop Communication Vocalized Summaries Vocalized Summaries Role clarificationRole clarificationSituational AwarenessSituational AwarenessEvent Management (codes)Event Management (codes)Leveling HierarchyLeveling HierarchyConflict ResolutionConflict Resolution

Example: Situational AwarenessExample: Situational Awareness

Example: Leveling HierarchyExample: Leveling Hierarchy Example: SBARExample: SBAR

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Simulated Scenarios: TechniquesSimulated Scenarios: Techniques

ScenarioScenario DebriefDebriefInterrupted Scenario (teaching)Interrupted Scenario (teaching)PreteachPreteach skillsskills simulatesimulateRepeat scenario with a twistRepeat scenario with a twist

Always Prepare Learners PreAlways Prepare Learners Pre--scenarioscenarioAlways Debrief Learners PostAlways Debrief Learners Post--ScenarioScenario

Scenario TipsScenario TipsLayer ComplexityLayer Complexity

Teamwork + Cognitive skillTeamwork + Cognitive skillAllow PracticeAllow Practice

22ndnd ScenarioScenarioWithin DebriefingWithin DebriefingOn the wardsOn the wards

Role ReversalRole ReversalSurgeon play role of a nurseSurgeon play role of a nurseResident play role of family memberResident play role of family member

DebriefingDebriefing

Simulation Debriefing SkillsSimulation Debriefing SkillsSafe EnvironmentSafe EnvironmentInterdisciplinary Interdisciplinary debriefersdebriefersVideo AssistVideo AssistStructure of DebriefStructure of Debrief1. Reactions1. Reactions2. Probing understanding2. Probing understanding

NonjudgementalNonjudgemental3. Summarization3. Summarization

Mistakes are not crimes. Mistakes are not crimes. They are puzzles to be figured outThey are puzzles to be figured out

Debriefing Teams On the WardsDebriefing Teams On the Wards

What happened? Reactions?What happened? Reactions?What questions arise? What questions arise?

What could have been done differently? What could have been done differently? Reinforce positive behaviorsReinforce positive behaviors

Train leaders to debrief (culture of teamwork)Train leaders to debrief (culture of teamwork)Residents, Attendings, Nurse Managers, Nurse Residents, Attendings, Nurse Managers, Nurse EducatorsEducators

Opportunities: Codes, Rapid Response, Family Opportunities: Codes, Rapid Response, Family Meetings, Difficult patientsMeetings, Difficult patients

No Matter What Your ApproachNo Matter What Your Approach

Multiple disciplines in the same Multiple disciplines in the same roomroom extremelyextremely high yieldhigh yieldDedicated time to team training develops Dedicated time to team training develops the institutional culturethe institutional culture

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ResourcesResources

www.harvardmedsim.orgwww.harvardmedsim.orgSociety For Simulation in HealthcareSociety For Simulation in Healthcare






Point & CounterpointPoint & CounterpointClassroom BasedClassroom Based

Less costlyLess costlyGreater reachGreater reachEasier to adoptEasier to adopt

Simulation BasedSimulation BasedMore realisticMore realisticActivated Activated learning/engaginglearning/engagingSkill/Performance Skill/Performance Training emphasisTraining emphasis

Teamwork Training is a tool, not a solution…

Questions & DiscussionQuestions & Discussion

"Greater experience does not necessarily lead to expertise. One may simply make the same mistakes with greater and greater confidence."-Cochrane Report

teamwork training & crm

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