Will Enfinger, Gavin Gardner and Carole Durant from the U.S. Air Force, provide details on how the TeamSTEPPS™ program, and its simulation underpinning, help improve patient safety.  

Members of the ER respond to a TeamSTEPPS/Mock Code Blue scenario. (Photo: Will Enfinger)
Members of the ER respond to a TeamSTEPPS/Mock Code Blue scenario. Image Credit: Will Enfinger

Members of the ER respond to a TeamSTEPPS/Mock Code Blue scenario. Image Credit: Will Enfinger

In August 2009, the 673d Medical Group (MDG) at Joint Base Elmendorf-Richardson, Alaska, began a four-year journey to improve communication among health care teams. Seventeen staff members from inpatient, outpatient and ancillary services, including the Patient Safety Manager (PSM), were appointed by the MDG commander as the “TeamSTEPPS Change Team” and charged with developing a plan for the facility.

The Team Strategies & Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program meets the needs of a medical organization desiring to improve the quality of care offered to patients, and strengthen the competence of practitioners. TeamSTEPPS is a systematic approach developed by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to integrate teamwork into practice(1) .

The Change Team attended a three-day “Train-the-Trainer” course and drafted an implementation plan for education, coaching and mentoring with a focus on "Briefs," "Huddles," and "Debriefs”. It was decided, in addition to offering on-going TeamSTEPPS classes for current staff, a session would be added to the monthly Newcomer’s Orientation (Calendar Year 2010). This introduced the program concepts and encouraged participants to seek out unit-based facilitators in their area for additional training, mentoring and coaching.

A simulation requirement for all inpatient staff was also added in 2010; with the expectation they would practice using the various TeamSTEPPS tools while providing patient care. The delivery of the best evidence based quality of care ultimately depends on the competences of practitioners as well as the system that supports their work (2). Therefore, the Change Team recognized the need to develop a formidable program of simulation training to improve the standards of patient safety and realistic education by exposing practitioners to clinical challenges, allowing them to encounter and be responsible for “real life” situations.

Medical simulation can ameliorate patient trust and establish a system that operates to improve task performance through experience and exposure. The use of simulation wherever educationally feasible conveys a critical message to the clinician: patients are to be protected whenever possible and are not training commodities (2).

The TeamSTEPPS initiative outlined for inpatient units by the Change Team focused on awareness, education, and sustainment. The three-pronged approach adopted included: 1) An introduction to the tools used throughout the facility at Newcomer’s Orientation for newly arrived staff, 2) The opportunity on the “First Friday” of each month for formal TeamSTEPPS classroom instruction for all staff, and 3) Ongoing unit-oriented simulation exercises and mentoring by trained facilitators working in patient care areas. The Change Team was confident implementing these techniques for all units and each shift would not only increase the number of opportunities for communication, but would also result in a decrease in the number of events related to communication issues.

The first prong of the initiative is geared towards awareness, providing an introduction to the facility wide program during Newcomer’s Orientation. This 50-minute course highlights the use of Briefs, Huddles, and Debriefs and encourages staff members to seek out unit facilitators for additional training and practice in using the various tools. For staff members who have not completed a formal course, or desire a refresher on the key elements, a four-hour TeamSTEPPS course is offered on the “First Friday” of every month and acts as the second prong of the initiative; geared toward education. A simulation exercise is incorporated into the local program, and provides a first-hand opportunity for trainers to highlight and/or refer to specific tools or techniques as they are introduced, which may have been useful during the simulation exercise.

As an incentive to participants, Air Force-approved Continuing Medical Education courses and CNEs for staff are provided at no additional cost. The course is also taught for entire units, when requested. Several inpatient units have used this opportunity to provide a “refresher” during regularly scheduled training days to ensure everyone on the unit is familiar with the concepts.

A second aspect of the education prong was designed and implemented in August 2009 when the simulation director and PSM drafted a training plan which targeted several “high risk”, or “Priority One”, areas where communication issues are most critical. For the facility initiative the areas identified were the Emergency Room, Intensive Care Unit, Multi-Services Unit, Ambulatory Procedures Unit, Gastroenterology Clinic, Operating Room/Post Anesthesia Care Unit and Labor & Deliver/Perinatal Unit. Staff members in these areas are required to complete at least one simulation exercise each year.

A policy letter was signed by the MDG commander and individual training dates were tracked and reported quarterly. Outpatient clinics and several ancillary areas were identified as “Priority Two” units and are included under the Newcomer’s Orientation and mentoring portions of the plan.

A simulation schedule was established for all areas of the facility, with a focus on the Priority One units. Time was allotted for unit-based teams to conduct simulations in both the lab or in situ during daily shifts. The plan was revised upon the arrival of the contract Simulation Coordinator in early 2011 after process assessments revealed difficulties with scheduling an entire “team” to participate. Robust scenarios, based on actual unit events, were developed and the quality of the simulation experience was greatly improved.

The third, and final, prong of the initiative focuses on sustainment by providing ongoing coaching and mentoring within individual units. Facilitators, who are senior-level staff and oversee many of the units, are able to provide reminders on specific tools and techniques throughout a shift and demonstrate their effectiveness. This allows time and opportunities to observe individual and team behaviors as well as provide one-on-one coaching and mentoring for junior level staff. Throughout any given day, staff may call a team huddle to clarify issues as they arise, especially in situations where the strength of an idea or individual “halo effect” could lead to a poor outcome for a patient. Unit facilitators are able to monitor staff during their shift and provide on-going coaching with several key tools such as SBAR (Situation, Background, Assessment, Recommendations) for handoffs, or advocating for their patient.

No specific computer hardware or software is required for others to implement this initiative. Anyone working on the standardized Office platform may duplicate this project without additional training or experience. Familiarity with the TeamSTEPPS program is the only specialized requirement. Facilities planning to trend the data following full implementation of the TeamSTEPPS program will need to retrospectively review reports for a specified time prior to implementation in order to determine the baseline percentage and prospectively track the data as reports are submitted.

For the four-year period of this study, 2009 – 2012, a total of 78 of 344 (23%) event reports submitted noted an issue with communication; representing an overall decrease of 8% from 2009, the base year for this project. This followed full implementation of the TeamSTEPPS program in 2010. During that year, 24 of 103 (23%) event reports were linked to poor communication, and represents a decrease of 8% from 2009, when 21 of 67 (31%) event reports noted a communication issue. In 2011, the decrease continued, with 25 of 112 (22%) reports submitted noting a communication issue and was observed for a third successive year in 2012 when 8 of 62 (13%) events were identified with issues related to poor communication.

Three categories (blood/blood products, falls and medications) were deemed as “high risk” wherein communication is a key factor for patient safety. The category of blood/blood products observed a 100% decrease from a high of seven reports submitted in 2009 to zero in 2012 while falls decreased 61% from a high of 23 in both 2010 and 2011 to nine in 2012. Medication issues decreased 66% overall from a high of 59 in 2010 to 20 in 2012.

Air Force Chief Master Sergeant John Yun directs Coast Gaurd Petty Officer Second Class LeFleur during a TeamSTEPPS and ACLS scenatio in the Sim Lab. (Photo: Will Enfinger)
Air Force Chief Master Sergeant John Yun directs Coast Gaurd Petty Officer Second Class LeFleur during a TeamSTEPPS and ACLS scenatio in the Sim Lab. Image Credit: Will Enfinger

The increased number of opportunities for enhanced communication among the staff, including briefs and debriefs at the beginning and end of each shift, has resulted in an 8% overall decrease in events related to communication issues across the facility during a four-year period.

During this time frame, no obstacles or resistance to implementation were noted in any of the inpatient units, nor were any issues presented by facilitators with educating staff and employing the tools on individual units. Having the MDG commander, who is a cardiologist and also works in several of the Priority One units, as the executive champion has been a major factor in the success of the facility program.

Each morning, he and his executive staff meet for a morning brief in order to set the tone for the day. As issues crop up, the team huddles to determine how to handle the situation and identify who is responsible for given tasks. Feedback from the executive TeamSTEPPS course evaluations highlighted the importance of these daily Briefs and acknowledged all executive members did in fact have a “shared mental model” and understood what needed to happen. The support from the top to the bottom has created an environment of continued growth, education, and responsibility for all involved in the medical profession to improve patient safety and communication.

To date, this on-going TeamSTEPPS initiative has been highly successful on two fronts: 1) providing additional, structured opportunities for increased communication resulting in a decrease in the percentage of submitted inpatient event reports noting a communication issue over a four-year period, and 2) ensuring the on-going use of the TeamSTEPPS tools through simulation exercises, role-playing during staff meetings and coaching/mentoring of junior staff on a daily basis across all units.

Ongoing training of individual units also provides opportunities to develop role-playing situations that can be practiced during staff meetings or anytime the unit may be experiencing low census. Having multiple experiences builds confidence among the staff and ensures a safety net for everyone on the unit.  Simulation is something that teaches not only empathy for patients, but should also be used for those activities for which it is best suited, particularly for activities that are hazardous, involve uncommon or rare situations, or for which experiential learning is of greatest value.(3) Thus, more practice is created to improve patient care across the board.

The Change Team feels the greatest gift we can give our patients is the quality of care that comes with respectful discourse, continued practice, and experienced professionals.

About the Authors

Carole A. Durant, MBA, CPHQ is Patient Safety Program Manager, 673d MDG, JBER, Alaska is the Patient Safety Program Manager and a Master Team STEPPS trainer.

Gavin Gardner is the Director of the University of Central Florida’s College of Medicine Simulation Coordinator, He has worked in education and simulation for 12 years and designed the 673d MDG JBER Simulation Center

Will Enfinger spent seven years as a Hospital Corpsman in the US Navy as a nursing care provider and Field Medical Service Technician trained by the United States Marine Corps in combat casualty care. He was awarded the Operator of the Year award for all of Air Force simulation, and currently manages eight simulation labs across the Pacific Air Force.


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