what is the frame work for your outcome? Team structure
performance, attitudes ("feel"), knowledge ("think")
what are the skills ("do") of team performance
leadership, situation monitoring, mutual support, communication
Why team work
◼ Reduce clinical errors◼ Improve patient outcomes ◼ Improve process outcomes ◼ Increase patient satisfaction ◼ Increase staff satisfaction◼ Reduce malpractice claims
why do errors occur some obstacles
◼ Workload fluctuations◼ Interruptions◼ Fatigue◼ Multi-tasking◼ Failure to follow up◼ Poor handoffs◼ Ineffective communication◼ Not following protocol◼ Excessive professional courtesy◼ Halo effect◼ Passenger syndrome ◼ Hidden agenda◼ Complacency◼ High-risk phase◼ Strength of an idea◼ Task (target) fixation
High performing teamsteams that perform well:
◼ Hold shared mental models◼ Have clear roles and responsibilities◼ Have clear, valued, and shared vision◼ Optimize resources◼ Have strong team leadership◼ Engage in a regular discipline of feedback◼ Develop a strong sense of collective trust and confidence ◼ Create mechanisms to cooperate and coordinate◼ Manage and optimize performance outcomes
Barriers to team performance
◼ Inconsistency in team membership◼ Lack of time◼ Lack of information sharing◼ Hierarchy◼ Defensiveness◼ Conventional thinking◼ Varying communication styles◼ Conflict◼ Lack of coordinationand follow-up◼ Distractions◼ Fatigue◼ Workload◼ Misinterpretation of cues◼ Lack of role clarity
Core Team
patient coordinating teamancillary and support servicesadministrationcontingency teams
have the closest contact with the patient!
core team members
a group of care providers who work interdependently to manage a set of assigned patients from point of assessment to disposition
a core team
A team comprising those work area members who are responsible for managing the operationalenvironment thatsupports theCore Team
coordinating team
contingency team
A time-limited team formed for emergent or specific events and composedof members fromvarious teams
Ancillary support services
provide direct, task-specific, time-limited care to patients.provideindirect service-focused tasks which help to facilitate the optimal healthcare experience for patients and their families
administration
◼ Establish and communicate vision◼ Develop policies and set expectations for staff related to teamwork◼ Support and encourage staff during implementation and culture change◼ Hold teams accountable for team performance◼ Define the culture of the organization
effective team members
-Are better able to predict the needs of other teammembers-Provide quality information and feedback-Engage in higher level decision-making-Manage conflict skillfully-Understand their roles and responsibilities-Reduce stress on the team as a whole through better performance
interdependent
achieve a mutual goal through ----- and adaptive actions
effective team leaders
-Organize the teamIdentify and articulate clear goals (i.e., the plan)-Assign tasks and responsibilities-Monitor and modify the plan; communicate changes-Review the team's performance; provide feedback when needed-Manage and allocate resources-Facilitate information sharing-Encourage team members to assist one another-Facilitate conflict resolution in a learning environment-Model effective teamwork
delegation
Method of re-distributing tasks or assignments
what are the 4 steps of delegation
◼ Decide what to delegate◼ Decide to whom to delegate◼ Communicate clear expectations◼ Request feedback
Promoting & Modeling TeamworkEffective leaders cultivate desired team behaviors and skills through:
◼ Open sharing of information◼ Role modeling and effectively cueing team members to employ prescribed teamwork behaviors and skills◼ Constructive and timely feedback◼ Facilitation of briefs, huddles, debriefs, andconflict resolution
Team events
brief, huddle, debrief
brief
planning sharing the planShort session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
huddles
problem solvingMonitoring and Modifying the PlanAd hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan
debriefs
process improvementReviewing the Team's PerformanceInformal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors
leaders are responsible to
assemble the team and facilitate team events
anyone can --- a brief, huddle, or debrief
request
brief what occurs during planning
◼ Form the team◼ Designate team rolesand responsibilities◼ Establish climate and goals◼ Engage team in short and long-term
what is the briefing checklist
-Who is on core team?-All members understand and agree upon goals?-Roles and responsibilities understood?-Plan of care? -Staff availability?-Workload?-Available resources?
huddle what occurs during problem solving
◼ Hold ad hoc, "touch-base" meetings to regain situation awareness◼ Discuss critical issues and emerging events◼ Anticipate outcomes and likely contingencies◼ Assign resources◼ Express concerns
debrief what occurs during process improvement
◼ Brief, informal information exchange and feedback sessions◼ Occur after an event or shift◼ Designed to improve teamwork skills ◼ Designed to improve outcomes
debrief process improvement Explain design to improve outcomes
◼ An accurate reconstruction of key events ◼ Analysis of why the event occurred◼ What should be done differently next time
Debrief checklist
-Communication clear?-Roles and responsibilities understood?-Situation awareness maintained?-Workload distribution?-Did we ask for or offer assistance?-Were errors made or avoided?-What went well, what should change, what can improve?
Facilitating conflict resolution Effective leaders facilitate conflict resolution techniques through invoking:
◼ Two-Challenge rule◼ DESC script
Facilitating conflict resolution Effective leaders also assist by:
◼ Helping team members master conflict resolution techniques◼ Serving as a mediator
LeadershipBarriers
◼ Hierarchical Culture◼ Lack of Resources or Information◼ Ineffective Communication◼ Conflict
brief, huddle, debrief
Leadershiptools and strategies
Leadershipoutcomes
◼ Shared Mental Model◼ Adaptability◼ Team Orientation◼ Mutual Trust
a continuous process
Situation monitoring (individual skill), situation awareness (individual outcome), and shared mental model (team outcome).
Situation monitoring (individual skill)Process of actively scanning behaviors and actions to assess elements of the situation or environment
◼ Fosters mutual respect and team accountability ◼ Provides safety net for team and patient◼ Includes cross monitoring
What are the 5 key principles
Team structure, communication, leadership, situation monitoring, mutual support
Team Structure
Identification of the components of a multi-team system that must work together effectively to ensure patient safety
Communication
Structured process by which information is clearly and accurately exchanged among team members
Leadership
Ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources
Situation monitoring
Process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning
Mutual support
Ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload
what is cross monitoring
Process of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors
what occurs during cross monitoring
◼ Mechanism to help maintain accurate situation awareness◼ Way of "watching each other's back"◼ Ability of team members to monitor each other's taskexecution and give feedback during task execution
Mutual performance monitoring
has been shown to be an important team competency.
what are the components of situation monitoring
Status of the patientTeam membersEnvironmentProgress toward goal
status of patient
▪ Patient History▪ Vital Signs▪ Medications▪ Physical Exam▪ Plan of Care▪ Psychosocial Condition
Team members
▪ Fatigue▪ Workload▪ Task Performance ▪ Skill Level▪ Stress Level
I'M SAFE checklist an individual team member's responsibility
I= IllnessM= MedicationS= StressA= Alcohol and DrugsF= FatigueE= Eating and Elimination
environment
▪ Facility Information▪ Administrative Information ▪ Human Resources▪ Triage Acuity▪ Equipment
Progress toward goal
▪ Status of team's patient(s)?▪ Goal of team?▪ Tasks/actions that are completed or that need to be done?▪ Plan still appropriate?
What is situation awareness
The state of knowing the current conditions affecting the team's work
what occurs during situation awareness
◼ Knowing the status of a particular event◼ Knowing the status of the team's patients◼ Understanding the operational issues affecting the team◼ Maintaining mindfulness
Conditions that Undermine Situation Awareness (SA)Failure to—
◼ Share information with the team◼ Request information from others◼ Direct information to specific team members◼ Include patient or family in communication◼ Utilize resources fully (e.g., status board, automation)◼ Document
A Shared Mental Model is...
The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication.
perform
Teams that--- well hold shared mental models
How Shared Mental Models Help Teams
◼ Help ensure that teams know what to expect, so if necessary, can regroup to get on the "same page"◼ Foster communication to ensure care is synchronized◼ Ensure that everyone on the team has a picture ofwhat it should look like◼ Enable team members to predict and anticipate better◼ Create commonality of effort and purpose
avoid
Shared mental models help teams --- errors that place patients at risk.
When to share
◼ Briefs◼ Huddles◼ Debriefs◼ Transitions in Care
as soon as possible
Share information ----when a change occurs in the patient's status.
situation monitoring barriers
◼ Hierarchical Culture◼ Lack of Resourcesor Information◼ IneffectiveCommunication◼ Conflict◼ Time◼ Distractions◼ Workload◼ Fatigue◼ Misinterpretationof Data◼ Failure to Share information
situation monitoring tools and strategies
Brief Huddle DebriefSTEPCross Monitoring
Situation Monitoring outcomes
◼ Situation Awareness◼ Shared Mental Model◼ Adaptability ◼TeamOrientation ◼ Mutual Trust
Mutual support is the essence of teamwork
◼ Protects team members from work overload situations that may reduce effectiveness and increase the risk of error
task assistance
Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error
what is feedback
is the giving, seeking,and receiving of performance-related information among the members of a team
types of feedback
◼ Can be formal or informal ◼ Constructive feedback◼ Evaluative feedback
Constructive feedback
◼ Is considerate, task-specific, and focuses attention on performance and away from the individual◼ Is provided by all team members
Evaluative feedback
◼ Helps the individual by comparing behavior to standards or to the individual's own past performance ◼ Most often used by an individual in a coaching or mentoring role
Characteristics of Effective FeedbackGood Feedback is—
◼ TIMELY◼ RESPECTFUL◼ SPECIFIC◼ DIRECTED toward improvement -Helps prevent the same problem from occurring in the future◼ CONSIDERATE
Feedback
is where the learning occurs
Advocate for the patient
◼ Invoked when team members' viewpoints don't coincide with that of a decision maker
assert
a corrective action in a firm and respectful manner
the assertive statement
◼ Respect and support authority◼ Clearly assert concerns and suggestions◼ Use an assertive statement (nonthreatening and ensures that critical information is addressed)-Make an opening-State the concern- State the problem -Offer a solution-Reach an agreement
conflict resolution options Information Conflict(We have different information!)
two challenge rule
conflict resolution options Personal Conflict (Hostile and harassing behavior)
DESC script
Two Challenge Rule
Invoked when an initial assertion is ignored...◼It is your responsibility to assertively voice your concern at least two times to ensure that it has been heardThe member being challenged must acknowledge If the outcome is still not acceptable◼ Take a stronger course of action◼ Use supervisor or chain of command
Stop the line
two challenge rule to resolving conflict "Empower any member of the team to "------" if he or she senses or discovers an essential safety breach."This is an action never to be taken lightly, but it requires immediate cessation of the process and resolution of the safety issue.
Please use CUS words but only when appropiate
C- "I am concerned"U-"I am uncomfortable"S- "This is a safety issue
what is the conflict resolution DESC script
A constructive approach for managing and resolving conflictUltimately, consensus shall be reached.
conflict resolutionDESC script
D—Describe the specific situation E—Express your concerns about the action S—Suggest other alternatives C—Consequences should be stated
DESC- it Let's "DESC-it
◼ Have timely discussion◼ Frame problem in termsof your own experience◼ Use "I" statements to minimize defensiveness◼ Avoid blaming statements◼ Critique is not criticism◼ Focus on what is right, not who is right
collaboration
◼ Achieves a mutually satisfying solution resulting in the best outcome◼ All Win!: Patient Care Team (team members, the team, and the patient)◼ Includes commitment to a common mission ◼ Meet goals without compromising relationships"True ---- is a process, not an event.
team actions
◼ Foster a climate supportive of task assistance◼ Provide timely and constructive feedback◼ Be assertive and advocate for the patient◼ Use the Two-Challenge rule, CUS, and DESC script to resolve conflict◼ Resolve conflict through collaboration—Create a "Win-Win-Win" situationthose whom we support hold us up in life
JCAHO: importance of communication
Ineffective ----- is a root cause for nearly 66 percent of all sentinel events reported*
JCAHO Goals that relate to communicationNational Patient Safety Goals (NPSGs) related to communication:
◼ Improve the effectiveness of communication among caregivers-Read-Back - Handoff◼ Accurately and completely reconcile medications and other treatments across the continuum of care- Address specifically during handoff◼ Encourage the active involvement of patients and theirfamilies in the patient's care, as a patient safety strategy
Communication is
◼ The process by which information is exchanged between individuals, departments, or organizations◼ The lifeline of the Core Team◼ Effective when it permeates every aspect of an organization
standards of effective communication
Completeclearbrieftimely
standards of effective communication complete
◼ Communicate all relevant information
standards of effective communication Brief
◼ Communicate the information in a concise manner
standards of effective communication Clear
◼ Convey information that is plainly understood
standards of effective communication Timely
◼ Offer and request information in an appropriate timeframe◼ Verify authenticity◼ Validate or acknowledge information
information exchange stategies
◼ Situation-Background- Assessment- Recommendation (SBAR)◼ Call-Out◼ Check-Back◼ Handoff
SBAR provides...SBAR
◼ A framework for team members to effectively communicate information to one anotherCommunicate the following information: Situation―What is going on with the patient? Background―What is the clinical background or context?Assessment―What do I think the problem is? Recommendation― What would I recommend?Remember to introduce yourself...
Call out is..
A strategy used to communicate important or critical information◼ It informs all team members simultaneously during emergency situations◼ It helps team members anticipate next steps
Check back is
The steps include the following:1. Sender initiates the message2. Receiver accepts the message and provides feedback3. Sender double-checks to ensure that the message was received
what is handoff
The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm
what must occur during handoff
◼ Optimized Information◼ Responsibility- Accountability ◼ Uncertainty◼ Verbal Structure◼ Checklists◼ IT Support◼AcknowledgementGreat opportunity for quality and safety
I PASS THE BATON" stands for?
IntroductionPatientAssessmentSituationSafetythe BackgroundActionsTimingOwnershipNext
I PASS THE BATON" introduction
Introduce yourself and your role/job (include patient)
I PASS THE BATON" patient
Identifiers, age, sex, location
I PASS THE BATON" assessment
Present chief complaint, vital signs, symptoms, and diagnosis
I PASS THE BATON" situation
Current status/circumstances, including code status,level of uncertainty, recent changes, and response to treatment
I PASS THE BATON" safety
Critical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.)
I PASS THE BATON" background
Co-morbidities, previous episodes, current medications, and family history
I PASS THE BATON" actions
What ---were taken or are required? Provide brief rationale
I PASS THE BATON" timing
Level of urgency and explicit timing and prioritization of actions
I PASS THE BATON" ownership
Who is responsible (nurse/doctor/team)?Include patient/family responsibilities
I PASS THE BATON" next
What will happen --? Anticipated changes? What is the plan? Are there contingency plans?
communication challenges
◼ Language barrier ◼ Distractions◼ Physical proximity ◼ Personalities◼ Workload◼ Varying communication styles ◼ Conflict◼ Lack of information verification ◼ Shift changeGreat opportunity for quality and safety
situation monitoring process
of continually scanning and assessing a situation to gain and maintain an understanding of what's going on around you.
Situation awareness
is the state of "knowing what's going on around you.
shared mental model
results from each team member maintaining situation awareness and ensures that all team members are "on the same page.
Feedback Timely
given soon after the target behavior has occurred
feedback respectful
focuses on behaviors, not personal attributes
feedback specific
relates to a specific task or behavior that requires correction or improvement
feedback directed
toward improvement - provides directions for future improvement
feedback considerate
considers a team member's feelings and delivers negative information with fairness and respect
Mutual support team performance observation tool
Team structure, communication, leadership, situation monitoring, mutual support
Mutual support team performance observation toolteam structure
-Assembles team-Assigns or identifies team members' roles and responsibilities -Holds team members accountable-Includes patients and families as part of the team
Mutual support team performance observation toolcommunication
-Provides brief, clear, specific, and timely information-Seeks information from all available sources-Uses check-backs to verify information that is communicated -Uses SBAR, call-outs, check-backs, and handoff techniques tocommunicate effectively with team members
Mutual support team performance observation toolLeadership
-Identifies team goals and vision-Utilizes resources efficiently to maximize team performance -Balances workload within the team-Delegates tasks or assignments, as appropriate-Conducts briefs, huddles, and debriefs-Role models teamwork behaviors
Mutual support team performance observation toolSituation monitoring
-Monitors the state of the patient-Monitors fellow team members to ensure safety and preventerrors-Monitors the environment for safety and availability of resources(e.g., equipment)-Monitors progress toward the goal and identifies changes that could alter the care plan-Fosters communication to ensure a shared mental model
Mutual support team performance observation toolMutual Support
-Provides task-related support and assistance-Provides timely and constructive feedback to team members-Effectively advocates for the patient using the Assertive *Statement, Two- Challenge Rule, or CUS-Uses the Two-Challenge Rule or DESC script to resolve conflict