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Patient Safety StrategyTeamSTEPPS
Dr Olufemi AinaConsultantAesculapius Healthcare Consultants
About Us
Competencies in Healthcare Project Management, Business Development, Idea Generation, Process Improvement, Financial Management and Healthcare Quality Management.
Master Trainers in TeamSTEPPS Patient Safety Strategies, Certified by the US. Department of Defense and Agency for Healthcare Research and Quality (AHRQ)
Certified Project Managers with Project Management Institute (PMI) in the United States.
Certified Quality Management and Process Improvement Experts with American Society of Quality (ASQ) .
USAID SHOPS (Strengthening Health Outcomes though Private Sector) Trainers on Financial Management for Medical Directors
Our Services
Only TeamSTEPPS Provider in Nigeria
Hospital Quality Management and Process Improvement
Hospital Business Advisory and Financial Management
Tailored Capacity Development for Healthcare Professionals
Hospital Marketing and Branding Service
Outsourced Hospital Management
Personal Experience
Young NYSC dr. in a GH, Lagos many years ago: ordered IM drugs, nurse uncomfortable, even though gave lower dose- respiratory arrest, called and answered promptly.
Young Father in a PH, Lagos: 2 years ago: overworked nurse (esp. with reports), set up IV line, suction didn’t work, sucked manually
Quality and Safety
Quality: the degree of the realisation of the reasons that the patient has come to the care hospital e.g. patient comes to for an operation.
Safety:results which are not the reasons for the patient coming e.g. ‘not catching an infection’ and he is implicitly confident he will not run the risk of this happening.
To a certain extent, ‘safety’ thus concerns ‘anti-quality’.
Classification of Medical ErrorsNear Miss is defined as an act could have harmed the patient but did
not do so as a result of: chance e.g. patient received a contraindicated drug but did not
experience an adverse drug reaction prevention e.g. a potentially lethal over-dose was prescribed, but a
nurse identified the error before administering the medication mitigation e.g., a lethal drug overdose was administered but
discovered early and countered with an antidote.
Adverse Events cause harm to patients—causing a large number of injury, disability, and death.
errors of commission e.g., prescribing a medication that has a potentially fatal interaction with another drug the patient is taking.
errors of omission (e.g., failing to prescribe a medication from which the patient would likely have benefited, which may pose an even greater threat to health.
WHO- Patient Safety Practice Processes or structures which, when applied,
reduce the probability of adverse events resulting from exposure to the health-care system across a range of diseases and procedures.
Healthcare-associated infection is a global problem with over 1.4 million people suffering at any given time.
Medical errors result in numerous preventable injuries and deaths.
Inadequate Patient Safety Data in African Region
WHO- African Region
Adverse events 4% to 16% of all hospitalized patients
Developing Countries estimated 5% to 10% of patients acquire one or more infections
Risk 2 to 20 times higher than in developed countries.
Sentinel Events Surgical Care- > 50% of Adverse Events, Unsafe injections, blood and medicines
African Countries Mali 18.9%, Tanzania 14.8%, Algeria 9.8%
Drugs 25% of medicines are counterfeit, poly-pharmacy, inappropriate use of antimicrobials; overuse of injections, lack of prescription guidelines, inappropriate self-medication, non-adherence to dosing regimes.
Patient Safety Movement
9
2006
Patient Safety and Quality
Improvement Act of 2005
Executive Memo from President
DoD MedTeams®
ED Study
Institute for Healthcare
Improvement
100K lives Campaign
“To Err is Human” IOM Report TeamSTEPPS
1995 1999 2001 2003 2004 2005
JCAHO National
Patient Safety Goals
Medical Team Training
Institute of Medicine Report
Impact of Error: 44,000–98,000 annual deaths
occur as a result of errors
Medical errors are the leading cause, followed by surgical mistakes and complications
More Americans die from medical errors than from breast cancer, AIDS, or car accidents
7% of hospital patients experience a serious medication error
10
Cost associated with medical errors is $8–29 billion
annually.
Federal Action:
By 5 years;
medical errors by 50%,
nosocomial by 90%; and
eliminate “never-events” (such as wrong-site surgery)
Medical Errors Still Claiming Many Lives
By Elizabeth Weise, USA TODAY
As many as 98,000 Americans still die each year because of medical errors.
The researchers blame the:
Complexity of Health Care Systems
Lack of Leadership
Reluctance of to admit Errors
Billing System that Reward Errors
11
05/18/2005
…little progress towards the goal
Leape and Berwick,JAMA May 2005
Hospitals have taken steps to reduce medical errors and injuries.
Examples:
Computerized prescriptions: 81% decrease in errors.
Including pharmacist in medical team: 78% decrease in preventable drug reactions.
Team training in delivery of babies: 50% decrease in harmful outcomes — such as brain damage — in premature deliveries.
Source: Journal of the American Medical Association
Improvements
Joint Commission Sentinel Events
12
Why Do Errors Occur—Some Obstacles
Workload fluctuations
Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective
communication Not following
protocol 13
Excessive professional courtesy
Halo effect Hidden agenda Complacency High-risk phase Task (target)
fixation
The Components of a Patient Safety Program
14
“Initiative based on evidence derived
from team performance…
leveraging more than 25 years
of research in military, aviation,
nuclear power, business and industry…to acquire team
competencies”
15
Team Strategies & Tools to Enhance Performance & Patient Safety
TeamSTEPPS Curriculum Contributors
16
•Department of Defense
•Agency for Healthcare Research and Quality
•Research Organizations
•Universities
•Medical and Business Schools
•Hospitals—Military and Civilian, Teaching and Community-Based
•Healthcare Foundations
•Private Companies
•Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)
Background: US Army Aviation
Army aviation crew coordination failures in mid-80s contributed to 147 aviation fatalities and cost more than $290 million
The vast majority involved highly experienced aviators
Failures were attributed largely to crew communication, workload management, and task prioritization
17
US Navy Breakthroughs: Tactical Decisionmaking Under Stress (TADMUS)
Cross-Training Stress Exposure Training Team Coordination
Training (CRM) Scenario-Based Training
and Simulation Team Leader Training Team Dimensional Training Team Assessment
18
US Air Force CRM History Mid to Late 80s AF
bombers and heavy aircraft started CRM training
1992 Air Combat Command developed Aircrew Attention Management /CRM Training
By 1998, CRM deployed uniformly across the AF
Steady decline in human factors based mishaps since CRM training deployed
AF Medical Service adapted training, rolled out in 2000
19
DoD Team Research and Innovations
Non-Healthcare• Combat Information
Centers• Joint Forces
Operations• Army Special Forces• Tank, Submarine, and
Air Crews
20
CRM
TeamHealthcare
ED, OR, L&D, ICU, Dental Whole Hospital Combat Casualty Care
…striving to be a high reliability healthcare system…
21
Indemnity Experience
20
11
0
5
10
15
20
25
Malpractice Claims, Suits, and Observations
Pre-Teamwork Training Post-Teamwork Training
Adverse Outcomes
50%Reduction
50%Reduction
(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN
1
1.2
1.4
1.6
1.8
2
2.2
2.4
June July August Sept Oct Nov Dec Jan Feb M arch April M ay
Avg
. Len
gth
of S
tay
(day
s)
Length of ICU Stay After Team Training OR Teamw ork Climate and P ostoperative Seps is Rates
(per 1000 discharges)
Group Mean
Low Teamwork Climate
Mid Teamwork Climate
High Teamwork Climate
0
2
4
6
8
10
12
14
16
18
AHRQ National Average
Teamwork Climate Based on Safety Attitudes Questionnaire
Low High(Sexton, 2006)Johns Hopkins
(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine
Results of Teamwork System50% reduction in adverse outcomes
Average length of ICU stay reduced by 50%
27% reduction in Nurse turnover
Decreased clinical error rate from 30.9% to 4%
Reduction by 50% in post-op sepsis rate
Teamwork Actions
Recognize opportunities to improve patient safety
Assess your current Organizational Culture and existing Patient Safety Program components
Identify teamwork improvement action plan by analyzing data and survey results
Design and implement initiative to improve team-related competencies among your staff
Integrate TeamSTEPPS into daily practice.
23
“High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."
…Improved teamwork and communications…
Ultimately, a culture of safety
Teamwork Is All Around Us
24
Knowledge Shared awareness about what is going on in the Team
and progress towards its goals. Team members are familiar with Roles and Responsibilities of their Teammates
Attitudes Team members have a positive experience, enjoy
working in teams and trust intention of Team mates
Performance Team members know when and how to back each other
up, be more efficient in providing care, and more readily identify and correct errors if they occur
Components of Team Performance
Outcomes of Team Competencies
Knowledge Shared Mental Model
Attitudes Mutual Trust Team Orientation
Performance Adaptability Accuracy Productivity Efficiency Safety
26
Team Structure
Leadership
Situation Monitoring
TeamSTEPPS Modules
Mutual Support
Communication
Team Structure
First step in implementing a teamwork system is Team Development
Delineates fundamentals such as team size, membership, leadership, identification and distribution
Check the ratio of ‘WE’s to ‘I’s to assess Team Development
Patients are part of the Care Team
Members anticipate needs of others, adjust to each other’s actions and have a shared understanding of plan of care
Leadership
Team Leaders impact effectiveness by: changing behaviours motivating members coordinating processes facilitating problem-solving
Leaders need to ensure Teams perform effectively and attain desired outcomes
Leaders monitor, diagnose and treat Teams
Tools include brief, huddle, and debrief
Situation Monitoring
To gain or maintain an accurate awareness or understanding of every situation in which the team is functioning
Results in a shared mental model among team members
Elements include STEP:Situation of PatientTeam MembersEnvironmentProgress towards Goals
Mutual Support
Also known as Back-up behaviour :allows teams to become self-correcting, distribute workload effectively and regularly provide feedback
Specific approach to conflict resolution
Each team member becomes part of the Safety Net
Communication
Most important component of Team Management.
Standardized information exchange strategies- SBAR, Check-back, Call-out, Handoff, and Checklists
Complete, Clear, Brief, Timely
Roadmap to a Culture of Safety
33
Catalytic event drives need for
change
Build team, strategy, buy-in,
establish goals
Implement Action Plan, Train,
Empower Others
TeamSTEPPSChange
Coaching
I’m staying right here. Yeah they’ll
be back.
What are they
doing?Why
do we need chang
e?
Jt. Comm.
Status
QUOFUTURE
Errorville
Celebrate wins! Staying the
courseSustaining
Develop Action Plan
Test Interventio
n(Outcomes)
Monitor, Integrate, Continuous Process
Improvement
Prepare the Climate
Profile of Patient Safety Officers
Advocates of Teamwork
Dynamic Presenters
Viewed as Leaders amongst peers
In positions that allow flexibility
What We Do
Fundamentals Course and Implementation Workshop for Hospital Leadership and Steering Committee
Assessing your Hospital in Patient Safety and Healthcare Team Functioning
Training your Healthcare Professionals in TeamSTEPPS Strategies
Developing your Quality Champions as TeamSTEPPS Coaches
Regular Assessment and Onsite Support
Certify Hospitals as TeamSTEPPS Hospitals
Contact Us
Phone- 08052064317, 08023277559
Website- www.aesculapiusvn.com
Facebook: Aesculapius Healthcare Consultants
LinkedIn- Aesculapius VN
Twitter- @AesHealthCon
Email- [email protected], [email protected]
Thank You Aesculapius Healthcare Consultants