Implementation from 0 to 60: MetroHealth s Story of Success Jackelyn Csank, EMT-P Joseph Golob, MD Julia Gorecki, BSN, RN, MBA Victoria Jenkins, BSN, RN, CNOR Jay Koren, RN, BSN Ken Salisbury, RN, BSN, CNOR Robert Smith, PhD Implementation from 0 to 60: MetroHealth s Story of Success Robert L. Smith, PhD Director, Medical Staff Assistance Program Director, TeamSTEPPS Regional Training Center MetroHealth Who is MetroHealth? Serving Cuyahoga County in Cleveland since 1837 One of the largest healthcare organizations in Northeast Ohio 700-bed medical center 17 community health centers 1
Staffing Over 476 Primary Care/ Specialty Physicians 1,230 Registered Nurses 145 Advanced Practice Nurses Training Programs Twenty-four Residency Programs Fifteen Fellowship Programs 1 st and 2 nd Year Medical Students, etc. 1035 students Patient Care at MetroHealth Care provided in 2014 28,000 inpatients 2,900 newborns delivered Over 1,000,000 visits in outpatient centers Over 107,000 visits to the Emergency Department TeamSTEPPS and MetroHealth 2013 Implementation Identified TeamSTEPPS Champion Established TeamSTEPPS Change Team Prepared Master Trainers Developed Steering Committee Agreed to Implement System-wide Developed Instructor Training Course 2
Organizational Change Team Organizational Change Team Quality Department OB/GYN Emergency Medicine Surgery Trauma / Burn Units Medicine Pediatrics Geriatrics PM&R Ambulatory Care Medical ICU Organizational Develop Simulation Center Communication Diversity and Inclusion Marketing MetroHealth Union Target Administration for Buy In Examples of MetroHealth s Administrative Buy-In 3
MetroHealth s Mission Leading the way to a healthier you and a healthier community through service, teaching, discovery and teamwork. MetroHealth s Values Service to Others Teamwork Accountability Respect Inclusion and Diversity Quest for Excellence 14 TeamSTEPPS and MetroHealth 2014 Implementation Emergency Department Critical Care/ Trauma/ Burn Units Operating Room and PACU Labor & Delivery, NICU and Post-Partum Administration, Strategic Planning, Foundation Physical Medicine and Rehabilitation Middleburg Hts. Ambulatory Care Ambulatory Surgery on Main Campus TeamSTEPPS and MetroHealth 2014 Establishment of Action Councils Part of Sustainability Clinical and Non-Clinical Areas Goals: Improve Patient Safety/ customer services Improve patient/customer satisfaction Improve Employee Satisfaction Improve Processes and Efficiencies 4
TeamSTEPPS and MetroHealth 2015 Approximately 1/3 of staff trained On Deck: Cardiology Pulmonology Internal Medicine Pediatrics Finance / Information Systems Ambulatory Network Environmental Services / Dietary / Textiles TeamSTEPPS Implementation: It's more than just training. It's a culture change. Social work Case Manager ICU Care: The Pieces Physicians Nurses Joe Golob, MD Trauma Surgeon and Surgical Intensivist Medical Director of Hospital Patient Safety Medical Director of the Surgical Intensive Care Unit. and Jay Koren, RN, BSN Nurse Manager, Surgical Intensive Care Unit Pharmacy Nutrition Respiratory PT/OT Patient and Family 5
Pre-TeamSTEPPS Culture Post-TeamSTEPPS Culture Physician Social work Case Manager Nurse Nurse Social work Case Manager Patient and Family Nutrition Patient and Family Respiratory Nutrition Patient and Physician Family Respiratory Pharmacy PT/OT PT/OT Pharmacy Care is given by teams of experts Care given by an expert team /not teams of experts The Process of Change 1. TeamSTEPPS Organizational Readiness Assessment Evaluates need, readiness for change, time, resources, personnel and sustainment of change 2. Surveyed the entire unit staff on their perception of patient safety, communication and job satisfaction Modified version of the AHRQ s Patient Safety Culture Survey SHARED RESULTS WITH STAFF! The Process of Change 3. Created a TeamSTEPPS Intervention TeamSTEPPS Rounding Improvement Project (TRIP) 4. Five hour TeamSTEPPS training for the entire unit 5. Implemented TRIP 6. Re surveyed the entire unit staff on their perception of patient safety, communication and job satisfaction SHARED RESULTS WITH STAFF! 6
Pre-TeamSTEPPS Patient Safety Grade Pre-TeamSTEPPS Communication Grade Positive (Grade A or B) = 73% Negative (Grade C, D, F) = 27% Positive (Grade A or B) = 70% Negative (Grade C, D, F) = 30% Handoff to Jay Koren TeamSTEPPS Rounding Improvement Project (TRIP) 1. Nurse initiates rounds, reviewing and presenting overnight events, concerns, and current clinical data 2. Physicians examines patient and discusses daily plan 3. Nurse summarizes the daily plan 4. Attending closes by asking the team if they have any unanswered questions, concerns and creates a follow up list for the remainder of the day. Sterile Cockpit! Major TeamSTEPPS Tools Used: briefs, call outs, checks backs, check lists, debriefs 7
Patient Introduction and Nurse Report Video Physician Forming Treatment Plan Video Nurse Summary Video Physician Summary Video 8
TeamSTEPPS Rounding Sheet FRONT Overnight issues and nursing concerns Vital signs / Drips / Labs Additional information: activity, lines/tubes, skin issues Plan summary BACK Review the rounding process Attending debrief check list Follow up items Problems Encountered with TRIP Implementation Angry night nurses Filling out the TRIP sheet is busy work Angry day nurses Reporting vitals and labs is a resident s job Impatient attending intensivists I have to wait for the nurse to round? Implementation of the sterile cockpit No interruptions? Increased time on rounds Not really! Post-TeamSTEPPS Patient Safety Grade Post-TeamSTEPPS Communication Grade Positive (Grade A or B) Pre TeamSTEPPS = 73% Post TeamSTEPPS = 91% Negative (Grade C, D, F) Pre TeamSTEPPS = 27% Post TeamSTEPPS = 9% Positive (Grade A or B) Pre TeamSTEPPS = 70% Post TeamSTEPPS = 81% Negative (Grade C, D, F) Pre TeamSTEPPS = 30% Post TeamSTEPPS = 19% 9
Continued TRIP Improvement Trained observers, blinded to the rounding team audited TRIP rounds 262 TRIP rounding observations Entire Team present during rounds: 81% All four parts of the rounding process used: 71% Identified issues: Nurse not always available for rounds TRIP sheet not always complete and legible Attending forgets to conduct the end of rounds debrief and summary Conclusions Utilize the TeamSTEPPS Implementation Guide Collect data and show the staff so they know personally what TeamSTEPPS is trying to improve in their unit Utilize frontline staff to create a project to be started during or immediately after training to show staff they are using TeamSTEPPS Continue to modify the process and make improvements Show the staff success! Us, Them, and CUS ing in the Operating Room: Moving toward safer surgery through TeamSTEPPS Vicki Jenkins, BSN, Manager of Central Sterile Processing and Ken Salisbury, B.S.N., R.N.,CNOR OR Nurse / Quality Improvement Facilitator Surgery at MetroHealth Only Level I Adult Trauma Center in the Cleveland, Ohio area 20 Operating Rooms Surgery Teams wear two hats: Trauma surgeries Elective Surgeries (i.e., hip and knee replacements) 10
These surgeons can replace an arthritic hip and restore a patient s independence and quality of life. In a trauma, they can save lives. They need instruments that are functional and sterile. How Do You Sterilize a Tray? Ultrasonic washer (five minutes) - preliminary cleaning Commercial instrument washer (20-35 minutes) thorough cleaning Assemble tray - manually check cleanliness and functionality. Every instrument must be totally free of any bio-burden Tray placed in the sterilizer (60 minutes) 270 degrees F and then time to dry. How Do You Sterilize a Tray? Sterilizer door is opened to allow the instruments to cool. If tray is pulled too quickly, water vapor condenses and causes a wet tray, negating the sterilization process. Entire sterilization process takes approx. four hours. If instruments are not cleaned effectively, the process is repeated or the tray is flashed in the Operating Room. If instruments are missing, OR staff must find substitutes. 11
What Happens If the Instruments are Not Right? Infections Injuries to patients and staff Delays in patient care Increased healthcare costs Staff turnover A Long Cleveland Winter OR and Central Sterilization were physically separated in 2005. They had been connected for decades. By winter of 2013-2014, conditions deteriorated. OR Staff encountered missing / contaminated instruments. OR staff felt they could not trust their instruments and began flashing instruments or using other trays. Stress level was high, morale was low, and staff dreaded coming to work. It became Us (Surgeons and OR Staff) versus Them (Central Sterilization). Learn to CUS Assertive Communication If an error is about to occur Stop the line! Spring 2014- Day One Culture Change March of 2014, MetroHealth was under new leadership, and our CUSing was heard by the new administration. Staff members from the OR, Anesthesia, PACU and Surgeons were selected to serve as TeamSTEPPS coaches/instructors. 22 instructors were trained- multidisciplinary group The instructors designed a four hour TeamSTEPPS training module specific to the Perioperative Area. 24 four-hour classes were conducted. 12
Spring 2014- Day One Culture Change Keys to Success: Leadership support Surgeon support Quality instructors with passion and resilience Relevant curriculum Brief/Huddle/Debrief - use your strengths Safe environment for open/honest discussion Spring 2014- Day One Culture Change What did we learn: There are hardworking, caring, and dedicated staff members in every department Everyone wanted to keep patients safe. Staff in Central Sterilization knew what needed to change but were afraid to speak up. We knew less than we thought about each other s jobs and needed TeamSTEPPS tools and techniques to work better together. Spring 2014- Day Two Culture Change It took almost a decade to create a culture of distrust. Changing this will be a long-term process. We are now talking, creating policies, and implementing the tools we learned in TeamSTEPPS. TeamSTEPPS is the framework and the toolkit to build a culture of trust to provide safer care. So, what happened in Central Sterilization? Summer 2014- Day Two Culture Change Perioperative TeamSTEPPS Action Council Consists of representatives from 15 disciplines/ job categories in Perioperative Services Issues are identified and interdisciplinary project teams are formed to find and implement solutions 13
Handoff to Vicki Jenkins July 2014 TeamSTEPPS Wrong Fit Leader Please Use CUS Words when appropriate! 56 14
Conflict Resolution DESC Script DESC D Describe the specific situation E Express your concerns about the action S Suggest other alternatives C Consequences should be stated Ultimately, consensus needs to be reached. 57 TeamSTEPPS Tools Brief Huddle Debrief 15
TeamSTEPPS Tools Handoff Checklists 100% 99.2% 100% 99.5% 99.5% January February March Quarter 1 2015 100% January February March April May Quarter 1 Quarter 2 2015 April 2015 16
TeamSTEPPS and CSPD Video Fast Track to Ebola Preparedness Using TeamSTEPPS Concepts Julia Gorecki, BSN, RN, MBA Director of Nursing, Emergency Department and Life Flight Operations and Joe Tagliaferro, DO Chief Resident, Emergency Department Objectives Ebola Virus Discuss value of TeamSTEPPS in Ebola/Emerging Infectious Disease Preparedness Planning Identify components of TeamSTEPPS used in the Ebola/Emerging Infectious Disease Protocols Discuss power of simulation in preparing teams for managing the Ebola/Emerging Infectious Disease Patients 17
Ebola Virus Disease (EVD) Preparedness Planning MetroHealth began planning for EVD in July, 2014 Increased urgency due to Texas case MetroHealth RNs on flight with nurse from Texas Public Concern furloughed nurses Prepared to care for patient under investigation (PUI) Multi-Team System (MTS) 70 Team Structure Core Team Situation Leader assembles care team Tools and Strategies Brief Role assignment, equipment checklist, shared mental model Checklist for safe donning/doffing Situation Monitoring Leader and team members Team Observation Tool ED Ebola Response 1. Team Structure o Situation Leader (SL) established o SL assembles care team o Nurse o Physician o PPE checklist reader o PPE helper o Relief nurse rotation o SL verifies that all equipment is available for patient care o SL holds team members accountable o SL actively shares information among team members Emergency Department Team Process Team Structure Leadership Situation Monitoring Mutual Support Communication 18
Team Observation Tool Team Process o Care team follows PPE protocols o Care team renders care to patient as dictated by situation o Care team communicates findings and needs 2. Leadership o SL conducts brief before any patient contact to review process, protocol, goals o SL conducts huddle as necessary to review progress toward the goal o SL empowers team members to speak freely, ask questions, and stop the line if a breach in protocol occurs o SL conducts debrief to review adherence to process and achievement of goals Emergency Department Team Process Team Structure Leadership Situation Monitoring Mutual Support Communication Coordinating Team Infection control team support Content experts Communication with CDC, local health departments Training Reinforce shared mental model Goals of preparedness Donning / Doffing Checklist Performance Activity: PAPR Inpatient Donning **BUDDY MUST BE PRESENT TO OBSERVE DONNING PROCESS Complete Vital Signs & PPE Checklist Ensure all parts of PAPR belt are in working order: Complete airflow test of machine Visually inspect the integrity of the tubing Check the expiration date of the filters Ensure battery pack is fully charged Change into blue surgical scrubs & impermeable work shoes Remove all jewelry, pagers, cell phones etc. Donning / Doffing Checklist Remove hospital ID badge Pull hair into a tie back if needed Wash hands Tape bottom of scrubs at ankle so they do not ride up Don white Tyvek suit except hood Buddy is to roll hood of Tyvek suit, tucking it into the back of the suit Step into the Tyvek trauma booties Put first layer of surgical gloves on over the Tyvek sleeves Tape circumference of each wrist 19
Team Process Contingency Team Support Core Team Environmental Services, Lab, Radiology Planning Protocols team meetings Include in Briefs Huddles Debriefs Shared Mental Model reduce fear Simulation training Communication PPE Inspection Checklist PAPR FILTER DATE CHECKED VISUAL TUBING INSPECTION BATTERY CHARGED AIRFLOW TEST INNER SHROUD TUCKED TYVEK SUIT GLOVES TAPED OUTER GLOVES TRAUMA BOOTIES ISSUES OR BREACHES: CHECKED BY: TIME IN SUIT: TIME OUT SUIT: PAPR Buddy Checklist Role of Leadership Support from Senior Leadership Communicate vision community support Support policies and procedures Team sent to Emory for training Equipment, supplies, training Financial Support Leadership Team Meetings with Coordinating Team Tools and Strategies Special Disease Containment Unit Team Structure Selection and Training Briefs Huddles Debriefs Daily Family Meeting Mutual Support and Situational Monitoring Stop the line and CUS Checklists - Equipment, Supplies, Processes, Safety with PPE, Caregiver 20
Caregiver Checklist BLOOD PRESSURE * Diastolic >105 * Systolic < 100 > 150 HEART RATE: * > [70% (220 Age)] * Any irregular rate/rhythm RESPIRATIONS: * >24 / min TEMPERATURE: * < 99.5 F WEIGHT: SKIN: * Open Sores, large rash, Or sunburn HYDRATION: Situational Monitoring Performed for all direct caregivers Baseline data Safe to don suit Monitored daily by employee health Handoff Communication Checklists for handoff SBAR patient handoff Team handoff at shift change Handoff to Jackie Csank The Team The Space.. 635 hours of Simulation 2,700 + Sim North + Morgue + Creepy Room + Soon to be Sim West 21
Simulation Power Apply knowledge Realistic appraisal of systems, processes and personnel Deliberate practice Direct Observation Recording Debriefing / Feedback Train to Mastery Simulation SDCU Design Team roles / structure Communication Mutual Support Doffing Checklist Situational Leader Team roles / structure Situational monitoring Communication Mutual support TeamSTEPPS and Doffing Video Results of Debriefing Insights / observations Improvements protocol revision Repetition / Video Applying lessons learned SDCU and Care Team Transport Team Lab 22
Staff Response Regional Treatment Center Impact of TeamSTEPPS Tools and Simulation Shift from Individual Caregivers to a Strong Team Shift from Raw to Well Done Shift from Uncomfortable to Comfortable Questions Contact Information Robert L. Smith, Ph.D. Director, TeamSTEPPS Regional Training Center MetroHealth System, Cleveland, Ohio Office: (216) 778-3399 Email: rsmith3@metrohealth.org 23