Safety culture is a facet of organizational culture that captures attitudes, beliefs, perceptions, and values about safety. A culture of safety is essential in high reliability organizations and is a critical mechanism for the delivery of safe and high-quality care. It requires a strong commitment from leadership and staff. In this course, a safe culture is promoted through the use of identifying and reporting patient safety hazards, accountability and transparency, involvement with patients and families, and effective teamwork.
Team Training
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Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)
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Strengthening Safety Culture Through Teamwork
Research shows that many errors can be attributed to breakdowns in teamwork and communication. In this module, participants will learn how safety culture can be strengthened though teamwork and communication. Participants will learn skills critical in the prevention and mitigation of medical errors.
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Eileen Kasda
Hello, and thank you for watching this video on team training.
Previously, we have discussed what it means to be an expert team and
why that's important and why that will impact the care patients receive.
In this video, we'll introduce team training and provide an overview of what it is,
how it gets used,
and what the evidence behind it is in health care.
As we discussed previously,
there's the three component model that really helps understand some of
the really vast literature on what we know about
teams and what makes teams effective from the inputs.
The interventions you can use to change inputs to
improve the performance of teams involve a broad range of organizational interventions.
Things like team composition,
changing who is on the team,
changing people's access to expertise.
An easy example of this is adding a pharmacist to
a multi-disciplinary rounds in the ICU can reduce medication errors.
We can also change the technology people have access to,
to facilitate their communication and their collaboration.
We can change and clarify roles in our work processes.
All these things can help us interact more
effectively and we can have culture change initiatives,
things that involve leadership,
supporting a professional code of conduct,
or other such interventions designed to make
our interactions more effective and again have a deference to
expertise instead of role-based value input exclusively on someone's formal role.
So, some of the mediators will have structured
tools around standardizing critical interactions.
These things are briefing and debriefing checklists, handoffs,
we'll talk about those a little bit more in our forthcoming videos.
And training and coaching interventions which we'll talk about here.
And this is to help us develop the skills we need,
again, to be a part of an expert team.
And for the outputs,
we can always stop and reflect.
Again, that's taking the time with regularity to think about how we're organizing
ourselves for this interdependent work and what can we do
to make ourselves more effective at meeting those demands.
So, team training in health care has been around for quite a while.
It was one of the earliest interventions recommended in this last,
most current focus on patient safety and quality.
In a review of the literature that came out five years ago, now at this point,
really indicated that there was
enough evidence behind team training that it was encouraged for adoption.
It did not make the strongly encouraged list,
but if you look at what's on there,
those are interventions target at very specific clinical risks.
Team training is a very broad topic designed to
prevent or protect from risks of communication failure that we talked about,
which can be difficult to nail down and identify ahead of time sometimes.
There's been much more evidence in recent years that team training can
effectively reduce risk of preventable harm and we'll talk about that moving forward.
You may or may not be familiar with the TeamSTEPPS model of training,
this was developed by the Agency for Healthcare Research and Quality and
the Department of Defense over 10 years now and has been implemented very broadly.
This is becoming the industry standard for health care team training models and it really
outlines the absolute basic components that should be addressed in a training program.
Those kind of five competency domains it touches on,
the first one is team structure,
which really gets people to try to understand and identify that who is on the team.
And in some health care settings,
that's not an easy question to answer.
So, it's really coming to terms with who is on this team, what are our roles,
what are our responsibilities in helping people understand, again,
how all the pieces fit together,
how our work's interdependent and what we can do to better manage that.
It also focuses on leadership behaviors.
Some very clear ones on specific delegation of
tasks to ensure everyone knows who's responsible for what,
how we're managing our resources collectively,
and also, how leaders model the expected skills.
We all look to our peers to understand what's normal,
what's expected in terms of how we communicate with one another.
Leaders have more of an influence on that than other people.
So, it's really a key piece of leadership as
the role model to be the change you want to see in the world.
Communication is the third bucket of skills.
This involves some very specific pieces of communication we'll talk
about in future videos, closed-loop communication,
that means verifying that critical information we send to people is heard and
understood as intended and using other very kind of clear,
structured communication tools where appropriate.
So, these last two skills really fit together.
The mutual support and the situation monitoring really kind of form
this idea of helping behavior.
With situation monitoring, we're attending to not just what's going on with the patient,
but also what's going on with our team members and how they are doing,
their own personal status.
We're looking for discrepancies between
their actions and our understanding of the situation.
And this idea of mutual support,
we're acting on that, we're stepping in to help people out.
We're stepping in to catch errors proactively and surface them and deal with
them and that includes a skill set for managing that effectively.
How do we jump in and provide task assistance?
How do we manage and resolve conflict effectively and how do we give
our team members feedback on how they're doing in a constructive and positive way.
And these kind of skills,
these competence areas fit together and form the kind of
content of many team training programs.
And as I said previously,
there's growing evidence that this is an effective approach
to addressing some of the issues we've been talking about.
As we'll talk about in training, the measurement component,
there's a kind of a hierarchy of things you look for when
you evaluate the impact of a training program.
The first is people need to respond positively to it.
They need to like it. They need to think it will help them in their work.
They need to intend to use it.
And people do that in this meta-analysis of team training.
It's generally positively received.
You also need to make sure that the training you are delivering is impacting knowledge.
So. The skills we just went through,
are people understanding those things?
Are they building their knowledge base about how they understand
their own team works together in a way that's actionable?
And team training does that on average.
There's a relatively small effect on the attitudes of
people involved and that's not uncommon.
People's attitudes change a little bit more
slowly than other things so they can learn new skills and,
over time, as they enact those will change their attitudes over time.
But it does have a positive effect on attitudes and it has
a large effect on behavior change so when people go back to their work unit,
they're better as leaders, they're better communicators,
they're better at helping behavior in their organizations.
So, those are all really positive things.
And again, team training is not new.
It came from the aviation world,
in the military world,
decades of research on this.
It has a positive effect overall on average.
But, of course, as with any organizational change initiative,
there is, of course, a failure rate and
some initiatives do better than others for lots of different reasons.
But we've done a review of the literature on some of the factors that,
we think, impact positively on the interventions.
And the first is that the programs that were
successful tended to have a much more systematic,
mindful approach to implementation.
The TeamSTEPPS model uses a train the trainer approach,
where staff from a clinical area serve that role,
that's one way to do it.
The converse poor way to do this is throwing
a module up on an e-learning and make it required learning,
no follow up, no planning,
no assessment, those types of things.
E-learning can be and has documented to
be an effective part of these solutions but on its own,
not going to have much of an effect.
And also the effective programs were part of a bigger picture.
Wasn't just a standalone initiative or a project that people felt
was going to not be there next month or next quarter.
But it was something that was more integrated into
the organization's approach to improvement.
So it was viewed as a lasting piece of the organization and how
business gets done and how work is done and not someone's pet project,
not a pilot, not a flavor-of-the-month initiative.
Along with that comes leadership and peer support.
For these types of organizational change initiatives,
it needs to be clear that the leadership is behind this and that they will back people
up for investing their time and effort in making these changes happen.
And for the peers, the informal leaders
definitely need to show and demonstrate that they believe in
the value of this and that they are making efforts to change how things work as well.
There's also an investment in doing this.
Well, not just the time we spend in training but
the things that make this a sustainable intervention which is coaching and feedback.
So having people there who can
give people advice and help in feedback on how they're exhibiting
these behaviors in terms of communication and leadership and helping
behavior and also having not just be again,
one module, one training session,
a one and done approach.
But we're integrating some of these concepts into our ongoing way of doing business.
Whether that's in recurring meetings,
or using some of these tools and language and concepts.
Whether that's integrating some of
the structure communication tools into electronic medical records,
lots of different ways to try to integrate these ideas into
ongoing practice and bridge the gap between training and change on the job.
And that gets to some of the key issues of what we can
do to improve our odds of success with interventions like these.
And for team training,
like many training programs,
we can think about what happens before that training,
kind of during and after that training.
And what happens during is likely the easiest thing to get right.
But what happens before and after are equally important.
And we end up spending most of our time
thinking about what we're going to do during that training session,
which of course is important,
but what we do before and after,
to plan for, to message it,
to make people believe what
they're about to receive in terms of new skills are important and valued.
And it's going to be a lasting intervention in and
not just a pilot or a program is very, very important.
So we can talk about the content of the training and what do you train?
For all those competencies,
you can focus on a piece of it,
you can focus on all five other different choices.
And there's pros and cons which we'll talk about.
And there's methods. How do you train it?
I mentioned previously, an online e-learning module that can be a critical piece of it.
We know that simulation is a key piece to improving teamwork skills.
It's very much about what you do.
And it's easier to learn the principles of good teamwork.
It's harder to put them into action on a regular basis and
simulation can help develop those behavioral skills.
And then the broader implementation strategy.
How do you make sure it works and again continues
working and it's not just a one and done kind of approach.
So there's lots of things to do.
So choices to make and how you run the before piece which involves
assessment and planning and messaging and communicating this to people.
And what's really encouraged is tying this to again other things people value.
Getting better teamwork is a great objective but if you can
link that to other performance indicators in the organization, that's even better.
They're becoming better team players because of things they already care about.
Delivering great care and having great outcomes for the patients.
During, again we talked about using simulation using
different types of delivery methods for
training and conducting an evaluation trying to understand how
well your training works and getting better over time.
And then again the pieces that happen after anyone training episode.
How do you deal with turnover in the organization?
How do you train new people?
How do you give people continuing opportunities to develop that skill?
As we talked about team expertise,
it's not just a static thing.
You need a development plan through
someone's career to help continuing to develop those skills.
And this will contrast two kinds of approaches to doing this.
The first one is kind of a shotgun approach where consider
all five of those competency areas and we're going to deliver those all at once.
This can be four hours of training,
it can be all day.
But the benefits of doing this is it's simple.
You do everything all at once,
and it really sends a strong message that the organization values us.
To some extent, to dedicate that much time to
an in-person training program is quite an investment.
The challenges of course are scheduling everyone to participate in
that one block of time or multiple big blocks of time.
And of course, people's attention.
If you cover all of that material at once,
how much can you expect people to remember?
How much can you expect people to use?
Going back, it's a lot to do at once.
Another approach that gets used commonly is it's more kind of distributed model, right?
So here, we're going to break
the content apart and we're going to give it to people over time.
We are going to introduce in smaller pieces over a more sustained period of time.
And in general, we know that that's a better way to
provide learning experiences to people,
distributing the practice or the exposure versus lumping it all together for teamwork.
This seems to be viable as well.
So the advantages here is,
it's flexible, as I said,
it's a better fit for how we learn and it's
more responsive to the practical demands on the unit for scheduling people's time.
The challenge is this gets a little more complex and it can
run into competing interests for other types of activities and training over time too.
So in this video,
we talked about team training's idea,
we introduced some of the basic content,
some of the ways to implement this intervention,
we showed it is effective.
There is a strong literature emerging,
and it's a valuable approached proving safety and quality.
In the next video,
we're going to dig a bit deeper into one specific skill, communication.
And talk about some more specific strategies for improving
that skill or team performance process.
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