Objectives 6/10/2015. Using TeamSTEPPS Tools to Partner with Patients and Prevent and Learn from Falls

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1 Using TeamSTEPPS Tools to Partner with Patients and Prevent and Learn from Falls Katherine Jones, PT, PhD Victoria Kennel, MA Denise Mazzapica, MSN, RN-BC Myrta Rabinowitz, PhD, RN, Navigating from Pilot to Best Practice: Partnering with Patients to Prevent Falls using TeamSTEPPS Spread of Best Practice Lily Thomas, Ph.D, RN, FAAN Myrta Rabinowitz, Ph.D, RN-BC Denise Mazzapica, MSN, RN-BC Objectives 1. Define how to engage patients in fall prevention strategies using TeamSTEPPS tools. 2. Describe the process used to spread this best practice across a health system. 3. Learn how to complete a Spread Plan Template for organizational use. 1

2 About Us Background 1. System Wide Falls Prevention Task Force Fall Reduction Toolkit Who s Falling Monitoring Target Populations- Emergency Department, Behavioral Health 2. Mobilization Programs All Hospitalized Patients Ventilated Patients 3. Partnership With Patients to Prevent Falls What is a Partnership? Partnership is defined as a relationship between individuals or groups that is characterized by mutual cooperation and responsibility for the achievement of a specified goal (Hook, 2006) When patients are made to feel control over their care, they feel safer and develop solidarity with the health care team (Spath, 2004) The Partnership Program 1. This program actively engages patients as confident and effective members of the Core Team. 2. Fall prevention interventions are embedded into four TeamSTEPPS tools; briefs, huddles, debriefs, and handoff. 3. Only 1 Accidental Fall among 250 patients enrolled in pilot program. 2

3 Our Vision Model for Spread Spread Inspire Partnership with Patients to Prevent Falls using TeamSTEPPS Methodology Inform Transform What needed to be done? What needed to be done? Design Spread Toolkit: 1. Action Plan 2. Facility Spread Plan Template 3. Presentation for Leadership 4. Lesson Plan for Staff Education 5. Lesson Plan for Patient Education 6. Invitation to Participate 7. Process Tracking Tool Plan Implementation: 1. Create site roll out plan 2. Educate patients and staff 3. Monitor process 4. Monitor outcomes 3

4 Interdisciplinary Education Best Practice Spread Template INSPIRE, INFORM, & TRANSFORM What needs to be done? Who is responsible? When will it be done? Introductory meeting: For organizational leadership to provide project information Nurse Education Nurse will identify the inclusion criteria: 1. Patient is identified as a fall risk or fall with harm risk 2. Patient is alert and oriented 3. Patient speaks English 4. Patient is capable and willing to participate Patient Education Patient will verbalize understanding of 4 TS Tools: 1. Briefs 2. Huddles 3. Debriefs 4. Handoff Infrastructure: Select Project Team Inspire: Create Buy in Inform: Educate Transform: (Structure & Process) Implementation Monitoring process and outcomes Weekly: first 4 weeks Monthly Evaluation Modifications Next Steps North Shore LIJ Health System:. Use with permission and acknowledgement Rolling Timeline Exemplars Electronic Medical Record INFORM Meet with facility/service leaders INSPIRE Announcement of spread/create buy in TRANSFORM Implementation June 2014 Present TRANSFORM Select Project Team INFORM Educate TRANSFORM Monitor and Evaluate 4

5 Exemplar 5N LIJ 5 North: Fall Risk Algorithm 5N A&OX3 PATIENT Initiate the Partnering with Patient Initiative All staff must reinforce safety awareness and education in all shifts Please reinforce our Safety instructions in the admission packet Communicate Initiative info in briefs & change of shift report Place GREEN sticker on census board next to pt. s name. NO FALLS! CONFUSED PT. Move pt. closer to nurse s station proactively when possible. IDENTIFY PT. AS A FALL RISK or FALL WITH HARM RISK. The 4 A s of Fall Prevention!!! Assess the individual patient Awareness of persons involved Alarm on & consistently checked Attention to calls, alarms, & rounds Communicate info in briefs and change of shift report. Patient safety is interdisciplinary. Place RED sticker on census board 5N 5N Created by: 5N Nursing Team Jennilynn Kobbe, RN Assistant Nurse Manager Sara Karshigeyeva, RN Nurse Manager HOURLY ROUNDING!!! WE MUST CHECK BED ALARMS ARE ON & ADDRESS ALL 4 P s!!! -Bed alarm ON Educate family & patient Assess need for 1:1, ECR Round q30 minutes Proactive Toilet scheduling Sustainment Spread Outcomes 1. Monitor Process and Outcomes weekly for first four weeks 2. Monitor Process and Outcomes monthly 3. Coach Partnering with Patients to Prevent Falls Using TeamSTEPPS Methodology NSLIJHS: 17 Hospitals Program Spread to date: 13/17 Hospitals 5

6 Using TeamSTEPPS Tools to Partner with Patients and Prevent and Learn from Falls TeamSTEPPS National Conference June 17, 2015 Victoria Kennel, MA Katherine J. Jones, PT, PhD Acknowledgement: Funding This project is supported by: Grant number R18HS from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. ( ) Subgrant #20871-Y3 from CAPTURE Collaboration and Proactive Teamwork Used to ReduceFalls safety/capturefalls/ Acknowledgement: Research Team University of Nebraska Medical Center Katherine Jones, PT, PhD Victoria Kennel, MA Dawn Venema, PT, PhD Jane Potter, MD Linda Sobeski, PharmD Robin High, MBA, MA Anne Skinner, RHIA,MS Fran Higgins, MA, ADWR Mary Wood The Nebraska Medical Center Regina Nailon, RN, PhD University of Nebraska at Omaha Center for Collaboration Science Roni Reiter Palmon, PhD Joseph Allen, PhD Methodist Hospital Deborah Conley, MSN, APRN CNS, GCNS BC, FNGNA 23 Objectives 1. Identify key challenges to conducting effective post-fall huddles and how to overcome these barriers to team learning 2. Identify best-practices in conducting post-fall huddles that facilitate immediate learning by front-line workers 3. Classify types of human error that contribute to preventable patient falls 4. Explain why post-event huddles and debriefs facilitate critical thinking, learning, and perceptions of teamwork 6

7 Falls: Quality and Safety Problem Prevalence (Oliver et al., 2010) 2% - 3% of hospitalized patients fall each year 30% - 51% of falls result in injury Benchmarks from National Database of Nursing Quality Indicators (Staggs et al., 2014) 3.4 falls/1000 pt. days 0.8 injurious falls/1000 pt. days Outcomes Cost $14,000 greater for 2% of fallers with serious injury (Wong et al., 2011) 1/11 Healthcare Acquired Conditions (HACs) PPS hospitals not reimbursed for Falls contribute to 40% of nursing home admissions (Tinetti et al., 1988) Fear of falling limits mobility (Tinetti et al., 1994) 25 As compared to other HACs, little progress made in decreasing falls since CMS ceased paying hospitals for conditions not present on admission. Why? (AHRQ Interim Update) Evidence indicates that teams decrease fall risk but how? Systematic review: Etiology of falls is multifactorial (Oliver et al., 2004), thus falls require a multifactorial/ interprofessional approach for prevention Systematic review: Themes specific to successful implementation of fall risk reduction programs include multidisciplinary implementation and changing attitudes of nihilism (Miake-Lye et al., 2013) Cohort pre-post designs: Fall risk has been reduced in studies where interprofessional team members were actively engaged in fall risk reduction efforts (Gowdy et al., 2003; von Renteln-Kruse et al., 2007) Theory: Effective teams are the fundamental structure for managing complexity/learning and implementing change in organizations (Edmondson, 2012; Higgins et al., 2012) 27 TeamSTEPPS Leadership Tools: Huddles and Debriefs Huddle an ad hoc meeting to regain situation awareness, discuss critical issues, and emerging events Debrief a planned meeting to exchange information to recount, document, analyze, and learn from an event to improve teamwork skills and outcomes tools/teamstepps/instructor/index.html/ 7

8 What is a Post-Fall Huddle? An ad hoc meeting immediately after a fall that includes staff caring for the patient and (ideally) the patient and family Useful to multiple stakeholders in multiteam system (MTS): Patient and family Core team Nursing PT/OT Pharmacy Quality Improvement Providers Coordinating Team Administration/Management safety/capturefalls/tool inventory.html 29 Goals of a Post-Fall Huddle Contingency Team Goals 1. Discover root cause of the fall through group sensemaking (critical thinking) and learning 2. Decrease the risk of a future fall for the patient who has fallen by changing the plan of care for that particular patient Overarching MTS Goals 1. Decrease fall risk for all patients by applying what is learned in the huddle to the system 2. Improve trust among bedside personnel (core team) 3. Improve collaboration and coordination among component teams 30 Compare and Contrast Participating with Poll Everywhere How to vote via text messaging FIRST POLL: SUBSEQUENT POLLS: Aha2 RESPONSE You ve joined AHA Org s session (AHA1). When you re done, reply LEAVE AHA2 your response your response 8

9 Photo citation: LzXpn_Zdt I/TcRHbuyIcaI/AAAAAAAADsc/MlSqSLjuehU/s320/blame.jpg 6/10/2015 Characteristics of ineffective huddles 1. Poor leadership 2. Blaming and critical comments 3. Unmanaged challenging/negative personality 4. Unreceptive staff 34 Huddle best practices that facilitate learning and action Pocket Guide safety/_documents/postfall huddle pocket guide.pdf Social and technical aspects to consider: 1. Establish the purpose 2. Include the right people 3. Huddle at the right time 4. Huddle in a meaningful location 5. Find the right facilitator to lead the huddle 6. Ensure facilitator effectively leads the huddle 7. Manage and elicit good huddle team member behavior 8. Use a form or guide to assist the process 35 9

10 Huddle Form safety/_documents/postfall huddle form.pdf Best Practices more than a checklist Social Behaviors Leaders engages patient first Leader sets tone for learning Leader provides feedback to staff Leader invites staff participation Team members have shared mental model of learning goal Technical/Check List Establish the facts Leaders uses the guide but lets the story emerge 38 Best Practices more than a checklist Social Behaviors Leader summarizes and invites additional input specifically from patient Members contribute what they know and didn t know including the patient Members educate patient Technical/Check List Identify root causes as the story emerges Identification of root causes leads members to identify solutions at two levels 1. Patient 2. System 39 Best Practices more than a checklist Social Behaviors Members take responsibility for communicating results to their departments/discipline Leader educates members Leaders summarizes key learning points as a narrative and returns to the goals of improving patient and system safety Technical/Check List Specifically consider communication across disciplines and departments Establishing risk of injury Identified changes needed to patient plan of care and system coordination 40 10

11 Process Uncertainty Learning Domains Low High (MacPhail & Edmondson, 2011) Low Task Error Judgment Error *Completed later by coordinating team* Actor Interdependence High Coordination Error System Interaction 41 MTS Definition and Typology Two or more [component] teams that interface directly and interdependently in response to environmental contingencies toward the accomplishment of collective goals. (Mathieu, Marks, & Zaccaro, 2001, p. 290) Component teams achieve proximal goals MTS achieves overarching/organizational goal Characteristics Composition Development Coordination (Zaccaro, Marks, & DeChurch, 2012) Nursing: Reliably conduct purposeful hourly rounding QI: Standardize reporting taxonomy Fall Risk PT : Consistent/Safe Transfers & Mobility Pharmacy : Safe Medication Use/ Debridement MTS Components and Linkages IP Contingency Team (56% Nursing) IP Core Team (84% Nursing) IP Coordinating Team (40% Nursing) Data Event Information Who, What, When, Where Patient Information System Information Event Sensemaking How, Why Patient Sensemaking System Sensemaking Audit Bedside Interventions Conduct Root Cause Analysis Benchmark Rates Patient Action Conduct Gap Analysis: Integrate Evidence from Mult. Disciplines Conduct Annual /New Emp. Training & Assess Competencies Develop Policies/Procedures (e.g. Communication of Fall Risk) Choose Fall Risk Assessment Tool(s) Develop Fall Event Reporting Forms Collect, Analyze Fall Event Data Provide Feedback about Actions Taken System Action Patient Outcome (Fall?) System Outcome (Fall Rate) Changing Perceptions of Core Team *p<.05 calculated using random effects ANOVA and adjusted for nesting by hospital 44 11

12 Post-event Huddles/Debriefs Coordinating mechanism for MTS Accountability Predictability Shared mental model Change frame of reference (Okhuysen & Bechky, 2009) Training in error recovery is cognitively effective Detection Reflection Generation of recovery mechanisms Facilitates learning and future action (Dror, 2010) Cognitive sensitization to error Summary Huddles that facilitate critical thinking and learning balance technical and social aspects Huddle leader/facilitator activity is key to managing staff behavior, interaction, and learning Accurate error classification guides recovery actions to improve patient, team, and system actions and outcomes Post-event huddles and debriefs facilitate critical thinking and learning and affect perceptions of teamwork because they are a mechanism for coordination across the MTS References AHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to Available at Accessed March 22, AHRQ. TeamSTEPPS Accessed May 29, Dror, I. (2011). A novel approach to minimize error in the medical domain: Cognitive neuroscientific insights into training. Medical Teacher, 33, Edmondson AC. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: John Wiley & Sons; Gowdy M, Godfrey S. Using tools to assess and prevent inpatient falls. Jt Comm J Qual Saf. 2003;29(7): Higgins MC, Weiner J, Young L. Implementation teams: a new lever for organizational change. J Organiz Behav. 2012;33: MacPhail L. H., & Edmondson, A. C. (2011). Learning domains: The importance of work context in organizational learning from error. In D. A. Hofmann & M. Frese (Eds.), Errors in Organizations (pp ). New York: Routledge. Mathieu, J. E., Marks, M. A., & Zaccaro, S. J. (2001). Multiteam systems. In N. Anderson, D. Ones, H. K. Sinangil, & C. Viswesvaran (Eds.), International handbook of work and organizational psychology (pp ). London, UK: Sage. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158: Okhuysen, G. A., & Bechky, B. A. (2009). Coordination in organizations. The Academy of Management Annals, 3, Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age Ageing. 2004;33: Staggs VS, Mion LD, Shorr RI. Assisted and unassisted falls: different events, different outcomes, different implications for quality of hospital care. Jt Comm Jrnl. 2014;40: Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol. 1994;49:M140-M147. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. The New England Journal of Medicine. 1988;319: UNMC Patient Safety: CAPTURE Falls Tools Inventory. Accessed May 29, UNMC Patient Safety: CAPTURE Falls Tools Inventory Post-Fall Huddle Pocket Guide. Accessed May 29, UNMC Patient Safety: CAPTURE Falls Tools Inventory Post-Fall Huddle Form. Accessed May 29, von Renteln-Kruse W, Krause T. Incidence of in-hospital falls in geriatric patients before and after the introduction of an interdisciplinary team-based fall-prevention intervention. J Am Geriatr Soc. 2007;55(12): Wong CA, Recktenwald AJ, Jones ML, et al. The cost of serious fall-related injuries at three Midwestern hospitals. Jt Comm J Qual Patient Saf. 2011;37: Zaccaro, S. J., Marks, M. A., & DeChurch, L. (Eds.) (2012). Multiteam systems: An organization form for dynamic and complex environments. New York: Routledge. Contact Information Victoria Kennel victoria.kennel@unmc.edu Katherine Jones kjonesj@unmc.edu 12