# Presentation: 116781

## Implementing Team Training at Duke

- Karen Frush, BSN, MD
- Chief Patient Safety Officer
- Duke Medicine

## THE JOURNEY

- PICU
- Peri-operative Services
- GSK Collaborative
- NCHA Collaborative
- Comprehensive Implementation across Duke Medicine

## Team Training:  One more initiative??

- Time and workload
- Adding one more assignment onto everything else
- Best model?
- Lack of data to demonstrate improved outcomes
- Many consultants and approaches
- Required for all team members?
- Logistics:  Shut down the ORs?
- Cost vs benefit

## Teamwork Training ProcessPhase I:  Pre-intervention

- Chose to work with consultants
- Gathered pre-training data
- Knowledge test
- Attitude:  Sexton Teamwork and Safety Climate survey
- Behavior:  Conducted Real-time Observations
- Outcome data
- Processes
- Clinical outcomes
- Analyzed Secondary Measures
- Staff satisfaction and work culture
- Patient satisfaction

## Teamwork Training ProcessPhase II:  Training 

- Unit leaders involved with planning and implementation (J Mericle, J Meliones, K Mistry)
- 3 sessions to accommodate shifts
- Multidisciplinary group sessions
- Physician, nurse, and human factors facilitators
- Interactive session with hands-on tools
- Feedback allowed for further development
- Focused training for action at unit level
- Focused on tools and techniques to address unit’s issues

## Focused Unit Training Tools

- Handoff Communication
- SBAR: structured language
- Critical Language
- “I need clarity”: assertion
- “Sterile Cockpit”
- Focused attention
- Limit interruptions during Rounds
- Huddles for better planning
- White Boards

## Teamwork training processPhase III: Implementing change

- Leadership role models
- Multi-disciplinary (internal) coaches
- Interval observations, coaching by consultants
- Active participation of consultant experts in unit-based safety team meetings
- Phone calls at unit leaders’ preferred time, to review concerns and discuss barriers
- Train-the-trainer model used for new staff

## Teamwork Training ProcessPhase IV: Comprehensive Evaluation

- Immediate feedback of training session
- Change in Knowledge
- Change in Attitude:  Survey
- Behavior Change:  Observations
- Process or Practice Changes
- Impact on Clinical Outcomes
- Secondary measures

## TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

**Level 2 – Learning****: ****whether the training results in an increase in knowledge, skills or attitudes.**

**Level 3 – Behavior****: ****whether participants change their behavior back in the workplace as a result of training.**

**Level 4 – Results****: ****whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. **

**TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL**

** ****Post-training reaction survey**

** ****Teamwork knowledge test.**
** ****Survey of attitude towards teamwork.**
** ****Survey of self-perceived communication skills.**

** ****Observation of teamwork behaviors during routine patient care. **

** ****Patient satisfaction survey.**
** ****Complication rate based on AHRQ PSI.**
** ****Length of hospital stay.**
** ****Adverse drug events.**
** ****Patients’ claims.**
** ****Staff satisfaction survey.**
** ****Nurse turnover rates.**

## Team Training Results: Will this training impact the way you do business?

**Not**
**Sure**

**Prob.**

**%**

**Def.**

## Team Training Results: Would you recommend this course to your co-workers?

**Not**
**Sure**

**Prob.**

**%**

**Def.**

## TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

**Level 2 – Learning****: ****whether the training results in an increase in knowledge, skills or attitudes.**

**Level 3 – Behavior****: ****whether participants change their behavior back in the workplace as a result of training.**

**Level 4 – Results****: ****whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. **

**TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL**

** ****Post-training reaction survey**

** ****Teamwork knowledge test.**
** ****Survey of attitude towards teamwork.**
** ****Survey of self-perceived communication skills.**

** ****Observation of teamwork behaviors during routine patient care. **

** ****Patient satisfaction survey.**
** ****Complication rate based on AHRQ PSI.**
** ****Length of hospital stay.**
** ****Adverse drug events.**
** ****Patients’ claims.**
** ****Staff satisfaction survey.**
** ****Nurse turnover rates.**

## PICU Post-Training Survey Responses Summary. Question: “The physicians and nurses here work together as a well-coordinated team (Fisher Exact Test p value=0.011)”

- PICU Post-Training Survey Responses Summary. Question: “I know the proper channels to direct questions regarding patient safety in this clinical area (p value=0.007)”

## TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

**Level 2 – Learning****: ****whether the training results in an increase in knowledge, skills or attitudes.**

**Level 3 – Behavior****: ****whether participants change their behavior back in the workplace as a result of training.**

**Level 4 – Results****: ****whether the training has affected process or outcomes such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. **

**TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL**

** ****Post-training reaction survey**

** ****Teamwork knowledge test.**
** ****Survey of attitude towards teamwork.**
** ****Survey of self-perceived communication skills.**

** ****Observation of teamwork behaviors during routine patient care.**

** ****Patient satisfaction survey.**
** ****Complication rate based on AHRQ PSI.**
** ****Length of hospital stay.**
** ****Adverse drug events.**
** ****Patients’ claims.**
** ****Staff satisfaction survey.**
** ****Nurse turnover rates.**

## Overall Teamwork in PICU (p value=0.0001, fisher’s exact test)

## TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL

**Level 2 – Learning****: ****whether the training results in an increase in knowledge, skills or attitudes.**

**Level 3 – Behavior****: ****whether participants change their behavior back in the workplace as a result of training.**

**Level 4 – Results****: ****whether the training has affected process or outcomes, such as increased production, improved quality, reduced adverse events, decreased costs, or return on investment. **

**TEAM TRAINING EVALUATION BASED ON KIRKPATRICK’S FOUR-LEVEL EVALUATION MODEL**

** ****Post-training reaction survey**

** ****Teamwork knowledge test.**
** ****Survey of attitude towards teamwork.**
** ****Survey of self-perceived communication skills.**

** ****Observation of teamwork behaviors during routine patient care. **

** ****Patient satisfaction survey.**
** ****Process or practice changes.**
** ****Length of hospital stay.**
** ****Adverse drug events.**
** ****Patients’ claims.**
** ****Staff satisfaction survey.**
** ****Nurse turnover rates.**

## Slide 18

**Notes:**
Typically “handoffs” occur at the bedside as shown in yellow. A good handoff actually begins prior to the patient ever entering the PICU. This is outlined in light blue.  

##  OR – PICU Hand-Off Turnaround Time: 

** ****OR – PICU**** ****Hand-Off Turnaround Time: **
**             ****Before and After Intervention**

- Turnaround Time (minutes)

## Operational Changes, Improvements in outcomes

- Time to critical labs drawn at hand-off
- Briefings and debriefings implemented; SBAR communication for nursing report, telephone communication
- Decrease in infection rates
- Decrease LOS and increased throughput
- Patient Satisfaction score exceeded target (Press Ganey)
- Work Culture survey score increased

## Implementing TeamSTEPPSacross Duke Medicine

*TeamSTEPPS* has helped us overcome some initial barriers to team training
- 4 phase approach to be undertaken throughout high acuity areas at DUH, DRH and DRaH
- Training with specific tools and concepts (modules) in intermediate units and non-clinical areas
- Collaborative with UNC SoM, SoN
- Assertion and speaking up
- TeamSTEPPS and simulation, virtual training