By Alex McEllistrem-Evenson, Editor, Health Workforce News
Teamwork is important in many professions, but in health care, it becomes an issue of life and death. For Dr. Ryan Fringer, MD, this realization may have come just in time.
“A few years ago, the attending trauma surgeon and I were standing in the back of the Trauma Room and were not able to hear each other’s voice because of the noise and chaos in the room,” states Fringer. “After that experience, we – along with other attending and resident physicians from our departments – committed ourselves to quality improvement by enhancing how we work as a team.”
It is moments like this one, along with the publication of seminal research relating to patient safety and best outcomes, which have led in recent years to a concerted focus on teamwork in health care work environments. Emerging from this movement is TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), a unique course developed by the Department of Defense and adapted for usage in health care settings by the Agency for Healthcare Research and Quality (AHRQ) and the U.S. Department of Defense.
Dr. James Battles, a patient safety researcher with AHRQ who serves as the federal leader for the TeamSTEPPS program, clarifies the need: “We talk about the health care team but we don’t do it particularly well,” he states. “Over the years if you look at causal factors for preventing medical harm on health care-associated injury, communication and teamwork are common underlying factors in most adverse events.”
“In many cases,” Battles continues, “we understand that teamwork is important, but we have people who don’t define themselves as part of a core team. Most often in practical settings, particularly in community-based hospitals, the physician group doesn’t necessarily view themselves as part of the hospital team. Exacerbating that problem is the way that we do most health and professional training in individual professional silos. We have very limited opportunity for inter-professional teamwork.”
The program itself essentially teaches health care providers how to view themselves as part of a team in a conscious and active manner. “TeamSTEPPS has made several concrete improvements to how we practice in our emergency department,” states Dr. Ric Pardini MD, a TeamSTEPPS master trainer employed at Mountain View Hospital in Madras, Oregon. “Patients and their families are encouraged to be part of our huddles so they can understand what is happening to them and around them. Staff members are empowered to speak up confidently and they are given the skills to do so effectively.”
What sets TeamSTEPPS apart, however, is its pedagogy. Using what Battles calls a “train the trainers approach,” select representatives from a given facility take a two-and-a-half-day-long course that enables them to return and implement the program. “We call them master trainers,” clarifies Battles. “They’re the change agents. No single group can do it all. We focus on training a cadre of leaders who then go out and train directly within the health care system. Many other places go back and do training sessions for their own individual instructors, creating more master trainers. It encompasses three or four levels of training.”
In addition to master trainers, TeamSTEPPS relies on “coaches,” who provide ongoing support for the program following the initial training. “That’s often at a unit-based level,” states Battles. “We know that training alone does not equal improved teamwork. You’ve got to work at it really hard, constantly coach, reinforce the principles of the program, and retrain when new staff are hired. There’s no magic bullet here.”
Deborah Milne, RN, MPA, a Senior Research Scientist with the American Institutes for Research (AIR) who serves as the Director of National Implementation for the TeamSTEPPS program, states that “the number goes up all the time, but right now we’ve trained about 1500 individuals from 250 organizations to go back and train people at their facilities.” In addition to coordinating TeamSTEPPS training, AIR continues to develop TeamSTEPPS curriculum on behalf of the Department of Defense and AHRQ.
Because of this trickle-down approach, it’s difficult to assess not only the total number of providers receiving TeamSTEPPS training – Battles estimates it to be “somewhere around 10,000”—but also the specific nature of the training each of these people have received. Battles and Milne are fine with that.
“We recognize that there’s no one way to implement TeamSTEPPS,” muses Battles. “We prepare the TeamSTEPPS materials in what we call a flexible training kit because we know that each institution will have to adapt, modify, and make the materials and resources fit their own particular setting; we encourage that. The basic principles and concepts remain the same, but implementation will be different for every organization.” This is evident when examining ways in which TeamSTEPPS has been implemented in different settings.
Kristi K. Miller, MS, RN, is the System Director of Clinical Safety with Fairview Health Services in Minneapolis, Minnesota. Fairview, a health care system with seven hospitals and 48 primary care clinics, has implemented TeamSTEPPS as part of a multifaceted approach to patient safety spearheaded by Miller and her counterpart, Dr. Stan Davis, who were both part of the first group to become TeamSTEPPS master trainers in 2007.
“We don’t just do the didactic training,” states Miller. “We believe you need to know in the context of your work environment when to utilize these skills.” Fairview makes use of a number of methods in addition to TeamSTEPPS to address this concern, including in situ simulation (simulating emergencies and holding a guided debriefing with all interdisciplinary participants focusing on teamwork and communication rather than technical skills) and Just Culture (a work focusing on accountability, managing error, and being transparent). “In the past, we all assumed that the presence of an expert individual clinician guaranteed safety. Today, we know that we need to insure safety by providing individuals with the skills to become expert team members. TeamSTEPPS really gave us a way to talk about teamwork in a much more organized manner,” states Miller. “It provides the lexicon which is what we know; In Situ Simulation provides that environmental context which constitutes what we do. We think that combining TeamSTEPPS with the experiential nature of in situ simulation allows providers to practice their teamwork skills in the context of their work environment. It gives us a way not only identify errors or gaps in process or communication but also to mitigate error.”
On the other end of the spectrum is Pardini, who has implemented TeamSTEPPS in small critical access hospitals in rural areas of Oregon. The program was so successful that Pardini and a team developed their own TeamSTEPPS course, to train additional trainers in the state. “With funding from Oregon Health Sciences University’s Office of Rural Health and the Oregon Rural Healthcare Quality Network, we completed our first course in April 2010, training master trainers from ten additional Oregon hospitals,” he states.
By definition, critical access hospitals represent the only accessible health care option for many of the residents in their client base; as such, there is less room for error. For Pardini, the benefits of TeamSTEPPS in these facilities is clear: “By improving our communication skills and by including the patients and the patients’ families in our discussions of the care plan, we’ve been able to increase the speed of the team during intense critical care situations and we’ve been able to identify and correct shortcomings in the delivery of that care. Not only have we identified several potential medical errors, including incorrect dosage orders, protocol errors, and the unavailability of important supplies and medicines, we’ve also experienced an increase in patient satisfaction and staff satisfaction.”
These positive results are also attributable to ways in which Pardini and his team have adapted the TeamSTEPPS curriculum to serve their own needs, establishing a peer-to-peer TeamSTEPPS orientation program. “I have been told by almost every hospital that the biggest hurdle to implementing TeamSTEPPS is a lack of physician buy-in. The perception is that physicians won’t buy in to a system where no one member of the health care team is elevated up on a pedestal.”
Fringer, the Residency Program Director in the Department of Emergency Medicine for William Beaumont Hospital in Royal Oak, Michigan, agrees. “The one thing that TeamSTEPPS doesn’t do – and with good reason – is define roles and responsibilities. I think it’s an area that a lot of hospitals—especially those with training programs—have some inherent difficulties with,” he states.
Pardini’s approach to peer-to-peer orientation may be a viable solution. “I’ve presented the orientation to two hospital medical staffs, once in Nebraska and once in Oregon. In both cases, the physicians were eager to use the safety tools once they realized two things: medical mistakes are huge problems at every hospital, and the safety tools are easy to implement. In fact, one physician arrived as a skeptic and left immediately after the orientation to hold a debrief for his team following their administration of thrombolytics to an acute stroke victim. The response to these peer-to-peer physician orientations has been so positive that they’ve been requested for two more hospitals in Nebraska and ten in Oregon.”
Miller raises another concern, related to the time it takes to train staff in health care systems when human resources are already stretched to their limit. “The TeamSTEPPS book is large—over 800 pages—and their course is more than two days long. Getting people off a unit for that long to attend a course is problematic,” she states. In response, Miller and Davis’ team have broken the program into shorter training sessions, “from four hours all the way down to thirty minutes.”
“That’s our challenge,” adds Battles, “to get recognition that teamwork is an issue. It’s beginning to happen, but then how do you do it, how do you get the time, who’s going to get the leadership to buy in? It’s not just training people, it changes the way we do our business.”
At the same time that teamwork training is changing the business of health care, it appears that the nature of health care is undergoing fundamental changes, as new challenges related to teamwork are beginning to emerge.
“Our major focus,” states Battles, “has been on teamwork at a unit-level that typically works together – OB units, ICUs, surgical teams, and so forth. Then we move out to teamwork on floors within hospitals, for example. But one of the major issues being addressed in health care reform, and it’s a major issue, has to do with virtual teamwork, relating to the coordination of care across different organizations.”
“How do you deal with teamwork issues when multiple providers may not necessarily be in the same room? How do you create integration and coordination with organizations who are not structurally integrated or coordinated? It takes the meaning of teamwork to a different level of complexity and of absolute need,” remarks Battles. “We’re working on it, but we don’t really have the complete answer yet.“
Interestingly, the TeamSTEPPS program may be uniquely poised to address such concerns. Originally developed by the Department of Defense, the program represents an all-too-rare example of a successful collaboration between two separate governmental departments traditionally unaffiliated with one another. Battles acknowledges this: “Speaking for Heidi King, my counterpart at the Department of Defense, we feel that this has been a real success story in terms of the Department of Defense and the Department of Health and Human Services working together to solve a problem in health care delivery.”
To the extent that the success of the TeamSTEPPS program can be examined as a model of effective collaboration, the dominant characteristics seem to be the program’s intrinsic flexibility, adaptability, and simplicity. “We felt it absolutely imperative to get resources and materials that were in the public domain,” states Battles, referring to the origin of TeamSTEPPS.
This adaptability seems to allow for mutual understanding, an essential component of effective teamwork, not only between individuals but also between facilities: “I’ve observed several of the TeamSTEPPS training centers over the last couple of years,” states Milne, “and one of the things that stands out the most is that people come from all over, but their problems are the same. There might be somebody from a large public hospital in a big city and another person from a critical access hospital in North Dakota in the same class – these people begin to talk about their problems and have this “a-ha” moment that their problems are the same. It’s a shock to them.”
According to Pardini, “TeamSTEPPS is a successful program because it is easy to implement and inexpensive to use. There are no complicated gadgets or mysterious magic wands. It’s all about straight forward tools to keep patients safe.” Many of these tools, it would seem, revolve around eliminating or reducing the power structure involved with basic semantics.
Fringer praises the way TeamSTEPPS “takes very vague terms like ‘leadership’ and ‘communication’ and puts concrete behaviors and skills to them,” a sentiment echoed by both Miller and Pardini. “We were surprised, to hear from people who have been slugging away in inter-professional education for a long time,” remarks Battles. “They have said that the existence of the TeamSTEPPS curriculum has given them a common language around which they can carry out inter-professional training which wasn’t there before. We were thrilled that people are discovering that.”
Pardini elaborates on the degree to which effective teamwork emerges when everyone involved with a given patient’s care and well-being are both empowered to speak and trained to listen effectively. “Since incorporating debriefs,” he states, “we have identified and corrected multiple problems and inefficiencies, and we have greatly increased the amount of positive feedback and constructive criticism shared amongst the staff members.”
“Our department has become a better place to work,” he continues, “but more importantly it’s become a better place to be a patient.”
That, it would seem, is an essential goal upon which everyone can agree, regardless of profession or facility, and the degree to which TeamSTEPPS and other patient-safety initiatives are successful likely depends on the degree to which these initiatives maintain their focus on the patient.
For more information about TeamSTEPPS, the TeamSTEPPS National Implementation Project or to find out if your organization is eligible to receive Master Trainer training preparation under the TeamSTEPPS National Implementation Project, send an e-mail to TeamSTEPPScontact@air.org or visit the Web site, http://teamstepps.ahrq.gov.