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Best practices for improving performance and patient safety

Learn how TeamSTEPPS® training and tools and other best practices have helped these health care organizations improve performance, quality and patient safety.


stock photo of surgeonThe surgical services department at Harborview Medical Center in Seattle had set a goal of increasing efficiency, communication and teamwork in the department, which included the operating room, recovery room, pre-anesthesia clinics and sterile processing. Its leadership turned to Ross Ehrmantraut, R.N., clinical director, team performance at UW Medicine and WWAMI Institute for Simulation in Healthcare (WISH). A longtime University of Washington Medicine nurse, who became involved in patient safety and now focuses on teamwork and communication, he now works with departments throughout the four-hospital system to learn skills around communication and teamwork that lead to profound and long-lasting culture change.

The UW Medicine team, led by Ehrmantraut, offers a menu of simple skills that are part of the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program, which was developed by the Department of Defense and Agency for Healthcare Research and Quality (AHRQ) using lessons learned in the aviation industry. Anyone can benefit from the skills, which can be taught in as little as a few hours. Ehrmantraut works with departments to identify the TeamSTEPPS tools to help when a department approaches him with a problem.

In the case of the operating room at Harborview, where the goal was to improve efficiency and get everyone on the team to have a shared mental model, he recommended (in consultation with key department representatives) a daily morning brief in every operating room to include surgeons, anesthesia, the circulator nurse and the scrub tech. In just three to four minutes, they discuss the day’s schedule to ensure everyone has the same understanding of the cases and what resources will be needed.

Ross Ehrmantraut headshotInitially there was some resistance to the idea of yet another meeting during the day, but Ehrmantraut explained that this one would be both short and crucial. “Before the briefing, they would find the first case of the day would go fine, but by the second or third case there was information they didn’t know about,” he explains. “They didn’t have the right equipment or the anesthesiologist didn’t know they needed a particular kind of anesthesia for this patient. Huge delays were occurring because everybody didn’t have a shared mental model of what the whole day looked like for that day, and for each surgeon.”

The “shared mental model” is a keystone of TeamSTEPPS and one of the goals of improved communication and teamwork skills. Ideally, everyone on a team is working with the same set of facts and expectations about their tasks.

The stakes are high in health care; for Harborview’s surgical services department, lost operating room time is expensive, particularly for a county-owned facility with few resources to spare. More importantly, unnecessary delays, and a lack of a shared mental model can impact patient outcomes.

Culture change is fundamental to many of the initiatives that hospitals launch, whether they are to reduce clinician burnout, identify unsafe practices or improve quality in a number of ways. While “culture change” sounds like a heavy lift, it actually comes down to the mindsets and daily choices of every individual in the organization.

That’s where TeamSTEPPS comes in. It teaches skills around teamwork and communication to staff and clinicians in every department throughout the organization, at any level. “It’s foundational to anything you can think of,” explains Christopher Hund, director of the American Hospital Association’s (AHA’s) Team Training program and director of quality for the Health Research & Educational Trust (HRET). “It’s not something to think of as another initiative. Instead it’s something that can support or fit into anything you’re already doing.”

Christopher Hund headshotTeamSTEPPS has transitioned from being run by HRET for AHRQ to now being part of the AHA’s Team Training function. Organizations usually send at least three people to the two-day training Master Training Course, available at one of five centers around the country. They can then come back and train others with some or all of the skills they have gained.

AHA Team Training staff can also come to a hospital or health system and provide customized training. These services run the gamut from a daylong workshop to embedding someone in the organization for a long period to better understand its culture and how it needs to evolve.

What is TeamSTEPPS?

AHA Team Training also sponsors free monthly webinars on various topics and hosts a yearly conference, where participants present research. Hund describes it as “a very community-driven event” with front-line staff who don’t often give presentations offering their successes and challenges with making teams work. TeamSTEPPS contains five major components:

  • Understanding the structure of a team, and the wide variety of people who should be considered part of a team; not just those carrying out the operation, but the scheduler and the staff who clean the operating room ahead of time, for instance.
  • Communicating clearly, concisely and completely: The training provides specific tools to help, such as using the same terminology.
  • Team leadership, and introducing the idea of “situational leadership,” which is the person who needs to oversee the task based on what the situation requires, not what their job title is.
  • Mutual support: asking for help when it’s needed. “People don’t like to ask others for help; they think it makes them look weak,” explains Hund. Teams require a certain level of vulnerability to others. They also require openness for each member to be able to say when they are uncomfortable with a potential safety issue.
  • Situational monitoring: “This is cultivating skills to understand what’s going on with yourself and then the ability to be aware of what’s going on around you,” Hund explains. “If everybody on the team comes to this awareness, hopefully it leads to a shared mental model so everyone is on the same page.”

While all of these skills can be taught in about three hours, they can also be broken into smaller chunks of learning.

Photo of a team of hospital employees working together on a projectAt University of Washington, 400 staff and clinical members in surgical services were each given 90 minutes of training in team communication skills, incorporating low-tech simulations into the sessions to reinforce the tools taught. As they progress, they continue to add additional tools from the TeamSTEPPS toolkit. “We found instead of trying to implement them all at once, we do one or two tools at a time and it doesn’t feel too overwhelming,” Ehrmantraut says.

UW Medicine has found that the training is sustained over time when at least one master trainer is embedded in the department that has adopted TeamSTEPPS methods, and Ehrmantraut, and members of the UW team, are available for ongoing consultations.

But organizations find success with the techniques in a variety of different ways that fit their own cultures, Hund says. TeamSTEPPS skills work best when the group using them is as diverse and inclusive as possible, so the communications skills are helping bridge different groups’ use of terminology and their approaches to their work. “Where it doesn’t work is when it is driven by just one group, such as nursing or the administration, and only one group of people starts using the tools.”

Partnering and best practices for improving patient safety

Case study 1: Ochsner implements new software in just six weeks
Even with efforts to standardize patient safety reporting across its sites, Ochsner Health System in southeast Louisiana lacked accurate and complete quality dashboard data for monthly and quarterly review meetings with senior leadership. The information was never complete because of a lag in reporting data. To overcome this challenge, Ochsner decided to purchase a new patient safety reporting system. Ultimately, Ochsner chose RL6:Risk from RL Solutions due to its cost and ease of use. The American Hospital Association exclusively endorses RL Solutions’ RL6:Risk incident reporting and management software. The AHA has appointed RL Solutions the AHA Champion Sponsor for Quality, as well as the sponsor of the AHA Quest for Quality Prize.

When Ochsner decided to purchase a new patient safety reporting system, the health system had just six weeks to make the switch from its existing software vendor. That left Ochsner scrambling to implement the new system, a process requiring getting buy-in from users quickly.

The organization relied in part on its internal communication mantra, “8 times, 8 ways”, which means Ochsner communicates a message eight times in at least eight different ways to be sure everyone hears and understands the message. Then it rapid-cycled the software implementations in one-month cycles incorporating both in-person and online self-training, and a “search and destroy” mission to get rid of a paper incident reporting form. Despite the short implementation time frame, Ochsner saw a 20 percent increase in safety reports with the new system and added real-time tracking for falls and pressure ulcers. Read more about Ochsner’s success in the case study The Fast Lane.

Callout: Ochsner is tracking falls and pressure ulcers in real time using RL Solutions’ RL6:Risk software, which has earned the exclusive endorsement of the AHA.

Case study 2: Bassett Medical Center improves patient safety in 15 minutes a day
Leaders at Bassett Medical Center in Cooperstown, N.Y., recognized that the organization’s culture of safety momentum was slowing, and leaders were not communicating in a meaningful way about safety concerns. So they began using daily morning safety huddles, bolstered by a number of novel approaches to sustain the effort over time. These included participation by the CEO and senior administrative and medical staff leaders, a monthly thank you gift to attendees, and recognition during the huddle for a “good catch” or providing outstanding care. Event reporting increased and was sustained by 51 percent with the huddles; turnaround time for analysis and action on events decreased from seven days to two; and 86 percent of participants said organizational teamwork was improved because of the huddles. Read more about Bassett’s safety huddle.

Case study 3: Clark Regional Medical Center uses safety boards to reduce HACs
Clark Regional Medical Center, a 79-bed community hospital in east-central Kentucky, reduced the frequency of 14 hospital-acquired conditions by 74 percent between 2010 and 2015. Hospital leaders attribute the improvement to an “excellent interdisciplinary community and meticulous, evidence-based clinical practices.” Clark Regional also incorporated the use of safety boards, a simple strategy that allows anyone, including patients and family members, to raise concerns about safety. A bulletin board is divided into three sections: red (identified), yellow (active) and green (resolved). Anyone can post a concern, and the items can be easily moved from one section to the next as the concern is addressed. More than 1,000 defects were identified and corrected between 2013 and 2015. Concerns ranged from poor phone reception in parts of the hospital to the design of an endotracheal tube holder in the intensive care unit. All of Clark Regional’s clinical and non-clinical units now use safety boards. Read more about Clark Regional’s safety boards.