Hi there, my name's Eric Black. I am an associate professor of pediatrics and education at the UF College of Medicine. I want to talk to you guys today briefly about TeamSTEPPS, which is a communication intervention that's been used in a lot of different clinical environments. So briefly we're going to cover a couple of things. I'm going to give you just a cursory overview of TeamSTEPPS. We're going to kind of understand some of its history antecedents. We're going to understand a little bit about the basic principles, and then we're also going to consider about how team communication impacts lots of other things that really matter in clinical environments: outcomes, satisfaction, cost to care, and obviously your satisfaction as health care providers. So what his TeamSTEPPS? TeamSTEPPS is just one of many different communications interventions. It was developed, gosh, now what, 10 maybe a little bit more than 10 years ago, 15 years ago by AHRQ in tandem with the DOD, and primarily it was developed for the VA medical centers. What it seeks to do is integrate basic teamwork practices in healthcare. It was developed primarily as a response to the 1999 IOM report that really changed a lot of the way we consider and think about healthcare delivery. But at its heart, TeamSTEPPS is not, it's not complex. It's simple communication-based collaborative strategies that help to foment good and cogent teamwork. So what's it supposed to do? Well naturally it's just one component of this grand plan to achieve the IHI's Quad aim, used to be the triple aim until Bodenheimer came along and then said, "Wait a minute, what about you know provider satisfaction, isn't that pretty important?" We can't achieve you know enhanced patient experience, optimal patient care and while at the same time reducing cost, that all comes at an expense and up until really he brought this earth shattering news to light, there was no recognition that we were kind of flogging the providers in order to get this done. But TeamSTEPPS is now seen as a component that can help to build a more positive practice environment, while at the same time achieving some of the outcomes that we're looking to achieve. So how does it do this? TeamSTEPPS is really built on five very simple key principles. We focus on team structure, focus on team communication, leadership, I think some people are surprised that you know one of the basic components of a team is they all have to have leaders. That doesn't necessarily mean that the leader is the same at all times. You could have some sort of fluid and distributed leadership model, but there is a need for leadership. This idea of situation monitoring that we're all watching each other, we've all got each other's back. We're all looking and supporting each other. And there is an acceptance and willingness of corrective intervention and corrective involvement from others. If I've made a mistake I want someone to help me out with that, or if I'm overwhelmed, I want someone to come and assist me, and that's that final component which is mutual support. So we want to create situations where everybody is watching everyone back, and everybody's willing to step in and assist someone when it's needed. Very simple stuff. So each of these five principles has some techniques that are associated with this, and these are all very simple techniques, probably things that you're already familiar with or you've heard about. For example, just to talk about communication, TeamSTEPPS encourages the use of SBAR, which is just a very simple pneumonic for reporting critical information in a very timely fashion. It encourages the use of call outs. If we're in a care environment, I want to be thinking aloud. If I'm in an acute care situation, I want to make sure I'm verbalizing my thoughts as I'm walking through what's going on with this patient that's in distress. It encourages check back through close loop communication something that many of us are very familiar with if we're in different environments. When I ask for one milligram per kilogram of drug X, the individual who draws that up says, "Hey, I'm drawing one milligram per kilogram of drug X." And then you know back and forth that way, so I know that that person has directly heard my instructions and I have heard what they're doing in response. And then finally, using a structured procedure for hand-offs. For example IPASS might be one. There are many different structured procedures to do this. At least in my world, I think they're all fine as long as it's uniform. I think one of the biggest sources of confusion amongst practitioners and particularly learners in general is the fact that depending on where you're rotating in, sometimes even in the same facility, the rules change. The hand-off structure changes, the mnemonics that that clinical service is using to talk about things changes. And nobody really tells learners or individuals who might be floating through that care environment about the changes in those rules, you're just expected to kind of unconsciously understand them. With TeamSTEPPS, it just seeks to create standardization. And standardization is really one of those critical components to being able to have a reliable reliant fault intolerant organization. So in terms of implementation, TeamSTEPPS is great because A, it's free. It's been readily adopted so the Veterans Administration uses TeamSTEPPS throughout its facilities. They've got multiple different TeamSTEPPS implementation sites where they actually do research on it. All of the TeamSTEPPS materials are available for free again online. You can have TeamSTEPPS certified trainers come to your facility and assist you in a train the trainer process. Obviously that's going to be something that comes at a cost. But key things that sometimes folks forget is that A, training takes time and you must have buy-in, and really it's executive level by-in that makes this happen. Back to the free stuff, there's an annual TeamSTEPPS conference for free. I don't really know of any other academic conference that's free. You just got to get there and you can walk on up and register yourself for free and actually get a whole lot of learning out of it. The other nice thing about TeamSTEPPS, it's been adapted for lots of different contexts. There's an outpatient version, an inpatient version, a version for dental providers. There's actually a version for K-12 classroom teachers believe it or not. The final piece, this is something that Eduardo Salas who's one of the authors of TeamSTEPPS really hits home about is that in order to be effective, TeamSTEPPS must be coached. And this goes back into point number five: time and buy-in. And the practice must be deliberate. So I've had the fortune of coaching a TeamSTEPPS implementation for the last two years at a clinical practice site at a rural clinic in North Central Florida. And this is a whole big old smattering of data and I apologize that A, the text is so small and so much of it. But this looks at a slew of different team-based assessments, the CPAT, the team composite scale and the team performance questionnaire across four different time periods, as we progress through our learning as a small clinic. And you can see that wow, we experienced a lot of perceived growth at least from the clinical providers. I am just now getting to our practice spaded outcome, but I can tell you one of the big markers that we looked at was hemoglobin A1c's in our type 2 diabetic population. And what we saw is some pretty dramatic reduction in hemoglobin A1c's. In some cases three and four point reductions. There's some contemporary research out there now that says that for each one point sustained reduction at A1c, it translates to about $120000 in lifetime cost savings to a health system. So this actually has a lot of meaning to me and I can't wait to be able to wrap that clinical data into kind of some of the affective perspective based data that we've got here. Is that we involved everybody in this training and it's really I think built a practice model that is much more collaborative now. And the investment from everybody in the mission of that clinic is very much more pronounced. So quick takeaways and I know I talk fast, I could probably talk for a couple of days just about TeamSTEPPS but this is an overview. A, working as part of the team isn't something that we just know how to do, but it's something we can be trained to do. And I think that was one of the key things that I learned a couple of years ago. I just made an assumption that anybody who is smart enough to be a licensed health care provider regardless of professions probably knew how to be an effective team member, and that's just not the case. That doesn't mean that they're bad people, it doesn't mean they're not smart. Okay? It just means that they haven't been taught some basic skills. Two, like I just said, it can be taught. Three, the skills are simple. Simple, simple, simple, and that's the best way to do things. Problem is it must be deliberately practiced, so it's got to be reinforced. In best cases it's coached. Fortunately there is, I'm just going to put one meta-analysis. This is this huge piece. We can see some really amazingly strong data that supports the efficacy of this intervention. And for those of you who aren't really into statistics, that D is called a Cohen's d. It's a measure of standardized effect size. Anything above a 0.6, 0.7 is considered a large effect size. So you can see across the board yeah, we've got a large knowledge base effect size and we've got a pretty good size medium large effect on behavior. But look at our outcomes. So we've got a solid median or medium effect across organizational level outcomes, safety climate based outcomes, patient outcomes, patient satisfaction and mortality. All of those things are pretty darn amazing. And the big thing about mortality, I don't want to gloss over this is, that is a -0.36 that we're reducing mortality. So I'm going to leave this as what does it mean for you. If you haven't already gotten this message from this course, teamwork is an incredibly important component of running a successful high quality clinical practice. We in this profession and I'm going to talk about health care at large are just starting to learn how to integrate some of these team-based practices into what we're doing in clinical settings. All of our knowledge about this stuff is actually coming from other highly fault intolerant professions, environments, aviation, military, nuclear regulatory industry. I think a lot of folks tend to say, "Well, but wait a minute, isn't the health care system more complex?" Maybe and maybe not. I would, I would offer that the aviation industry is extraordinarily complex, millions of passengers flying on hundreds of thousands of planes every week and very few of them are falling out of the sky, and very few of them are having what we consider major disturbances. Team training and teamwork are essential components of each of those three industries that I mentioned, and we've learned a lot and we'll continue to learn a lot from the things that they've been doing. The other thing that I can guarantee you is that this teamwork thing is not going away. It will be an increasing component of what we are doing in health care environments for the foreseeable future. So I appreciate your time and I'll leave you with these two links if you want to learn more about TeamSTEPPS. As I mentioned, I like it because it's free. I like free things and I like it because it's simple and effective.
