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					  Using Simulation in
TeamSTEPPS® Training

           To know and be able to apply the Event Based
               Approach to Training
           To know and be able to develop TeamSTEPPS
               training scenarios
           To know and be able to develop TeamSTEPPS
               performance measures
           To know and be able to conduct effective debriefs of
               team performance

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                                    TEAMSTEPPS 05.2

                                  Course Outline
           Phase 1. Scenario Development
                      Exercise
           Phase 2. Measurement Development
                      Exercise
           Phase 3. Debriefing
           Lessons Learned

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                                     TEAMSTEPPS 05.2

           Team skills are developed through practice and
           Simulation allows health care professionals to
               practice TeamSTEPPS skills and strategies in a safe
               learning environment
           Simulation includes
                      Role play
                      Part-task trainers
                      Human patient simulation
                      Standardized patients

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                                            TEAMSTEPPS 05.2

                                 Keys to Success
           Proper scenario design
                      Focus on learning objectives
                      Provide more than one opportunity to practice team
           Accurate measurement
                      Include process and outcome measures
                      Capture behaviors
           Debriefing
                      Learning happens in the debrief
                      Include feedback on how to improve performance

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                                          TEAMSTEPPS 05.2

                         TeamSTEPPS Resources
           Scenarios – Tab I
                      131 Vignettes
                      Organized by department and TeamSTEPPS skill and tool
           Team Performance Observation Tool – Tab A,
               Appendix C
                      Tool for observing team performance
                      Observers should practice using the tool
                      Can be adopted to a particular type of care

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                                         TEAMSTEPPS 05.2

             Event-Based Approach to Training (EBAT)
                    Not    a new method
                       U.S. Navy, Targeted Acceptable Responses to Generated
                        Events (TARGETs) (Fowlkes, Lane, Salas, Franz, & Oser, 1994)
                       FAA Advisory Circular 120-35C
                         Line Operational Simulations
                         How to design simulation scenarios
                    Health     care domain
                       Simulation Module for Assessment of Resident Targeted
                        Event Responses (SMARTER) (Rosen, Salas, Silvestri, Wu, & Lazzara,

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                                            TEAMSTEPPS 05.2

                                       Phase 1

           Scenario Development
                   1.   Specify teamwork skills
                   2.   Define learning objectives
                   3.   Choose clinical context
                   4.   Define event sets
                   5.   Define targeted responses

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                                      TEAMSTEPPS 05.2

                       Specify Teamwork Skills
              Skills are general categories of
               behavior you want to train
              Teamwork is too complex to
               train in a single scenario
                  Need to focus on a subset of
                  There are four core skills in

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                                        TEAMSTEPPS 05.2

                             Define Learning Objectives

                   Learning objectives should be explicit and
                       Focus on specific TeamSTEPPS behaviors
                       Include the following information
                           Performance – Specifies the behavior
                           Condition(s) – Specifies the conditions under which
                            the behavior occurs
                           Standards – Specifies the level of expected

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                                          TEAMSTEPPS 05.2

                    Example Objective

          Learning Objective: Uses two-
          challenge rule or CUS to advocate for a
          patient in labor experiencing frequent,
          strong contractions

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                          TEAMSTEPPS 05.2

                        Choose a Clinical Context

                   Medicine is a notoriously task-specific domain
                   Not all contexts are equal for training purposes
                   Choose a clinical context that affords opportunities
                    to perform
                   TeamSTEPPS provides 131 scenarios (Tab I)
                   Contexts should be appropriate for eliciting the
                    team behavior of interest

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                                     TEAMSTEPPS 05.2

                        TeamSTEPPS Scenario 86
      Sally Rodgers, a 25-year-old nullip in labor at term who is dilated 3 cm. This is
      a change from 2cm over the previous 90 minutes. Sally is having frequent,
      strong to palpation contractions that are extremely uncomfortable. She is
      trembling, complaining of nausea, and begging her nurse for pain relief. The
      patient’s primary nurse believes epidural anesthesia would be appropriate and
      informs the obstetrician (OB) attending. The OB attending states he wants the
      patient to be dilated 4–5 cm before she receives the epidural. The nurse
      reiterates to the attending OB that her assessment is that the patient is in
      active labor. Although Sally’s cervix has not demonstrated active labor yet, her
      nurse believes the pain relief and relaxation resulting from an epidural would
      be beneficial for the patient. The attending OB agrees to the epidural
      placement. The patient is fully dilated and begins pushing 3 hours after the

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                                     TEAMSTEPPS 05.2

                                   Clinical Context
           Scenario 86
                       Sally Rodgers, a 25-year-old nullip in labor at term who is
                        dilated 3 cm. This is a change from 2cm over the previous
                        90 minutes. Sally is having frequent, strong to palpation
                        contractions that are extremely uncomfortable. She is
                        trembling, complaining of nausea, and begging her nurse
                        for pain relief.

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                                           TEAMSTEPPS 05.2

                                  Define Event Sets
           Event sets are the building blocks of a scenario
           Event sets consist of:
                       Trigger – The incident to elicit the team behavior
                       Distracters – Characteristics of the situation (i.e., conditions)
                        in which the behavior is to occur
           Examples
              Trigger: The OB attending states he wants the patient to be
                        dilated 4–5 cm before she receives the epidural
                       Distracter: Sally has a strong contraction and screams

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                                            TEAMSTEPPS 05.2

                            Define Targeted Responses

           Targeted responses
                       Behavioral responses to each event set trigger
                       Expected levels of performance (i.e., standards)
           Example
                       Trigger: The OB attending states he wants the patient to be
                        dilated 4–5 cm before she receives the epidural
                       Response: The nurse uses two-challenge rule or CUS to
                        advocate to the physician that Sally should receive pain
                        medication now

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                                          TEAMSTEPPS 05.2

           Simulation scenarios should consist of 3-5 event
                       Provides more than one opportunity to demonstrate
                       Creates reliability
           Each event set should not include more than one
            trigger event
           Event sets can be created by breaking a clinical
            procedure into chunks
                       Embed triggers into these chunks

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                                         TEAMSTEPPS 05.2

                            Trauma Example
      Trauma Phase                                               Expected Team
        Event Set                                                   Behaviors
                       Patient arrives without       Leadership
                       advance notice ("zero          Team leader assembles team quickly
                       time")                         Team leader advocates a plan

                                                      Team leader advocates a plan based on
                                                        known information
                       Inaccurate or incomplete
       Pre-Hospital/   information from              Communication
          Transport    EMS/rescue team                Team members use call-outs and check-
                                                        backs to share accurate patient injury
                                                        information and discoveries through
                                                      Team members request information from
                                                        EMS/rescue when information has not
                                                        been provided

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                                        TEAMSTEPPS 05.2

                            Trauma Example
                                  Primary Survey
                                                                    Expected Team
         Trauma Phase            Trigger
                                                         Team leader may ask non-team
                                                           members to leave

                         Too many people in room
                                                         Team members communicate findings
                                                           and orders with clear call-outs and
        Primary Survey                                   Team members are not distracted by
                                                        Situation Monitoring
                                                         Team member identifies equipment
                         Equipment not working or           issue
                             is missing                  Team member remedies issue (e.g.,
                                                            replaces, fixes, or obtains needed
                                                            equipment) quickly

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                                      TEAMSTEPPS 05.2

                              Scenario Development
           Select a scenario from Tab I
           Identify/develop the following items
                       TeamSTEPPS skill
                       Learning objective(s)
                       Clinical context
                       Event set
                            Trigger and distracters
                       Targeted responses
           Be prepared to present your results

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                                              TEAMSTEPPS 05.2

                                      Phase 2
        Develop Measures
              1.    Consider level of analysis
              2.    Clarify purpose
              3.    Decide what to measure
              4.    Select a measure

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                                      TEAMSTEPPS 05.2

                    Team Performance Observation Tool
       Leadership                                       Mutual Support Rating
        Utilizes resources efficiently to               Provides task-related support
           maximize team performance                     Provides timely and constructive
        Balances workload within the team                 feedback to team members
        Delegates tasks or assignments, as              Effectively advocates for the patient
           appropriate                                   Uses the Two-Challenge rule, CUS,
        Conducts briefs, huddles, and                     and DESC script to resolve conflict
           debriefs                                      Collaborates with team members
        Empowers team members to speak
           freely and ask questions                     Communication Rating
       Situation Monitoring                              Provides brief, clear, specific, and
                                                           timely information to team members
        Includes patient/family in
           communication                                 Seeks information from all available
        Cross monitors fellow team
           members                                       Verifies information that is
        Applies the STEP process when
           monitoring the situation                      Uses SBAR, call-outs, check-backs
                                                           and handoff techniques
        Fosters communication to ensure
           team members have a shared
           mental model

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                                      TEAMSTEPPS 05.2

                           Consider Level of Analysis
            Individuals
                       MD
                       Nurse
                       Anesthesia
            Teams
                       Delivery team
                       C-Section team
            Multi-team – Team Structure
                       Core team
                       Contingency team
                       Administrative team

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                                              TEAMSTEPPS 05.2

                              Clarify the Purpose
           Diagnose root causes of performance deficiencies
                     Identify specific weaknesses

           Provide feedback
                     Relay information regarding strengths and weaknesses as a
                      remediation plan

           Assessment
                     Evaluate the level of proficiency or readiness

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                                         TEAMSTEPPS 05.2

                    Decide What to Measure
         Outcomes tend to be more quantifiable and answer
          the question ―What happened?‖

         Processes answer the question ―Why did it happen?‖

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                            TEAMSTEPPS 05.2

               Outcomes
                       Sometimes referred to as measures of effectiveness
                       Provide an indication of the extent to which the outcome of
                        the task was successful
                  Are important for most measurement purposes
               What outcomes could we assess?
                     Accuracy – Precision of performance (e.g., correct medication)
                     Timeliness – How long (e.g., time to incision)
                     Productivity – How much (e.g., patient volume in ED)
                     Efficiency – Ratio of resources required versus used (e.g., OR

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                                         TEAMSTEPPS 05.2

           Processes
                     Sometimes referred to as measures of performance (MOPs)
                     Explain how and why certain outcomes may have happened
                      (―Was the decision made right?‖ versus ―Was the right
                      decision made?‖)
                     Important when diagnosing root causes of performance
                      deficiencies and providing feedback or follow-on training
           Types of Process
                     Procedural – Taskwork
                     Non-procedural – Taskwork
                     Teamwork

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                                         TEAMSTEPPS 05.2

                       Measurement Tips
            Assess processes as well as outcomes when
             diagnosing performance deficiencies or providing
            Consider measuring at multiple levels to identify the
             weak link
            Provide multiple opportunities to perform the same
             task or skill over the course of an exercise

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                               TEAMSTEPPS 05.2

                                 Select a Measure
            Checklists
                       Consist of items/actions that have dichotomous answers
                        such as Yes/No; Right/Wrong; Performed/Not Performed
                       Example: Primary Survey ABCs
            Frequency counts
                       Indication of the number of times that a behavior, action, or
                        error occurs
                       Example: Use of CUS, SBAR, Two-Challenge
            Rating scales
                       Numerical or descriptive judgment of how well a task was

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                                          TEAMSTEPPS 05.2

                            Checklist Tips
         Best used with a scripted scenario versus ―free play‖
         Items should be related to triggers embedded into the
         Each item should represent a single action taken by
             the individual, team, or battlegroup
         Label or define the response category that you are

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                                 TEAMSTEPPS 05.2

                    Action/Behavior         Yes No
  Assess Airway

  Circulation/FAST Exam

  Exposure and Environment

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                          TEAMSTEPPS 05.2

                        Frequency Count Tips
         Frequency counts are better when measuring acts of
          commission than acts of omission
                Overt actions or errors versus failing to demonstrate a
                 particular behavior
         Frequency counts are good when you want to know
          how often a specific action is taken or task is
         Frequency counts can be recorded during a critical
          event in an exercise or throughout the entire scenario

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                                     TEAMSTEPPS 05.2

                               Frequency Count
            Communication                            Positive Instances



             Unintelligible Communications

            Mutual Support                           Positive Instances

             Task Assistance

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                                   TEAMSTEPPS 05.2

                           Graphic Rating Scale
1. The team leader assigned roles to the Trauma Team.
             Ineffective                                   Effective

                    1        2    3                4   5     6

2. The PGY2 used check-back to confirm orders.
                Strongly                                   Strongly
                Disagree                                    Agree

                    1        2    3                4   5     6

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                                 TEAMSTEPPS 05.2

                    Anchored Rating Scale
    Communication: Used check-back during
    trauma resuscitation.

        1                2                   3           4              5
   Did not             Used              Used            Used          Used
    use             check-back       check-back      check-back    check-back
   check-             once to         to confirm      to confirm    to confirm
    back              confirm             all           critical    all critical
                    care plan at     medication         orders,       orders
                    end of case         orders       primary and
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                                   TEAMSTEPPS 05.2

                                     Rating Scales
           Uses
                       Rating scales are good for assessing quality when it does
                        not equate to a sum of quantity
                       Rating scales are good for assessing tasks that are less
                        procedural in nature
                       Rating scales are better to use when you are evaluating
                        performance on a continuum
           Tips
                       Define or clearly describe what you are measuring
                       Include a specific stem or item to accompany the rating

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                                          TEAMSTEPPS 05.2

                     Develop a measure to assess
                    performance for the scenario you
                           developed earlier

                     Be prepared to present your

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                             TEAMSTEPPS 05.2

                                        Phase 3
              Debriefing
                    1.   Introduce the debrief process
                    2.   Describe what happened
                    3.   Conduct an analysis of performance
                    4.   Identify lessons learned

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                                        TEAMSTEPPS 05.2

                                 Description Phase
             Recap of what happened in the scenario
                   Team members share their perspectives on what occurred during
                    the scenario and reach common ground
                   This helps ensure everyone takes away similar lessons from the
             How measurement can help
                   Provides a structure for understanding the scenario
                       The event sets or behavior categories can be used to structure discussion
                   Focus on critical aspects of performance
                       Helps to keep the discussion focused on events relevant to the learning

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                                             TEAMSTEPPS 05.2

                                   Analysis Phase
             A systematic investigation of why things happened in
                the scenario as they did
                   The team focuses on understanding what went well and what
                    could have been done better
             How measurement can help
                   Can help compare the team’s performance with standards of
                       Were the TeamSTEPPS behaviors performed when necessary?
                        If so, were they performed correctly or could they be improved?

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                                           TEAMSTEPPS 05.2

            Application/Generalization Phase
             A look ahead to how the team can generalize what
                they learned in the scenario to their daily practice
                   The team generates lessons learned and discuss what
                    needs to be corrected and how to correct it
             How measurement can help
                   Explicit event sets can be used to draw parallels between the
                    scenario and the actual clinical environment
                   Explicit measures associated with these events help promote
                    reflection about how to transfer what went well to the actual
                    clinical environment

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                                       TEAMSTEPPS 05.2

                               Tip for Success 1
             Tip 1: Don’t overwhelm learners or observers —
                Keep it simple
                   People can integrate only a few key learning points from a
                   Observers have a limited attention span and frequently have
                    to multi-task. Don’t ask too much; you won’t like what you get
                   Rule of thumb: Have a key event every 1 to 2 minutes of
                    scenario time

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                                        TEAMSTEPPS 05.2

                               Tip for Success 2
             Tip 2: Telling someone how well they did is not good
             They need diagnostic feedback
                   Specific
                   Behaviorally focused
                   Descriptive

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                                      TEAMSTEPPS 05.2

                               Tip for Success 3
             Tip 3: Train observers
                   Training, by definition, is systematic. For measurement to
                    guide this process, it too must be systematic, reliable, and
                   Make sure everyone has common expectations about
                   Develop and use a scoring guide

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                                        TEAMSTEPPS 05.2

                                                Rater Scoring Guide
                        Team Behaviors                 Hit             Variation in Quality                 Miss
                                              all components          several, but not all         structured
                        SBAR – uses           (situation,             components were used         communication was
                        structured            background,             (e.g., the situation was     NOT used at all when
                        communication         assessment, and         presented and the            appropriate (e.g.,
                        (situation,           recommendation)         background leading to the    during a handoff)
                        background,           are present             situation was stated, BUT
                        assessment,                                   NO assessment or
                        recommendation)                               recommendation is

                        Call-out –            a team member           critical information was     critical information wa
                        verbalizes critical   clearly verbalizes      only verbalized to one of    not verbalized
                        information to the    critical information to the team members and not
                        entire team           all team members        all of them
                                              a sender initiated a a team member initiates         a sender initiated a
                                              message, the            communication and the        message but the
                                              receiver accepted       other team member            receiver DID NOT
                        Check-back –          the message and         provides verification of     provide feedback
                        uses closed-loop      provided feedback receipt and understanding,         confirmation, and the
                        communication         confirmation, and       but the initiator DOES NOT   sender did not verify
                                              the sender verified verify this understanding is     message was receive
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                                              message was STEPPS 05.2
                                                            TEAM      correct.

                                  Tip for Success 4
             Tip 4: Keep teamwork and clinical skills separate
                   Use ―dual debriefs‖
                       Provide feedback on teamwork skills as a team
                       Correct an individual’s major clinical deficiencies in a follow-up
                   Don’t overcomplicate the clinical nature of the scenario when
                    your main purpose is to train teamwork
                       Teamwork novices especially should be given the chance to
                        focus on teamwork in the scenario, not complex clinical issues
                       As the team members’ teamwork skills advance, more complex
                        clinical scenarios can be used

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                                            TEAMSTEPPS 05.2

                               Tip for Success 5
             Tip 5: Event-based methods involve more than just
                   Good training design practices
                   Good scenario design practices
                   Good debrief facilitation practices

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                                        TEAMSTEPPS 05.2

                          Teamwork Actions
           Apply the Event Based Approach to Training
           Able to develop TeamSTEPPS training scenarios
           Able to develop TeamSTEPPS performance
           Know how to conduct effective debriefs of team

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                              TEAMSTEPPS 05.2