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KPSims “Turning a Team of Experts into an Expert Team” Jeff Convissar MD National KPSims “Turning a Team of Experts into an Expert Team” Jeff Convissar MD National Risk Management Nancy Corbett RN MHA Regional Risk Management Sybil Solis RN Regional Risk Management © 2009 The Permanente Medical

We are continually learning in the ever changing environment of healthcare and medicine. We We are continually learning in the ever changing environment of healthcare and medicine. We are not perfect. We all may find or think that we have inadequacies during this course, but that is why we are here! None of us are perfect. This course is not to single anyone out or intimidate anybody, but to be used as a tool to keep us safe, competent, and competitive in this ever changing climate in the health care industry. Rex Rasmussen RN, ANM SRO

Hypothetical Work Environment Multiple information sources Incomplete, conflicting information Rapidly changing, evolving scenarios Fatigue, Hypothetical Work Environment Multiple information sources Incomplete, conflicting information Rapidly changing, evolving scenarios Fatigue, sustained operations Performance pressure, life/death outcome Time pressure Distractions & auditory overload

We Are Wired To Fail: Nominal Human Error Rates Errors of commission, e. g. We Are Wired To Fail: Nominal Human Error Rates Errors of commission, e. g. , misreading a label Errors of omission without reminders Errors of omission with embedded item Simple arithmetic errors with self-checking Inspector failure to recognize an error Error rate under very high stress with danger • Handbook of Human Factors and Ergonomics. 1997 Anesthesia drug administration errors- 1 in 130 cases • Self reported data, New Zealand, Alan Merry . 003. 01. 003. 1. 25

Why do Simulation? How many times do you get to practice a new procedure Why do Simulation? How many times do you get to practice a new procedure before you do it on a patient? Do you have to manage emergencies? Do you practice as teams for emergencies? Do you routinely debrief your real events?

Why Teamwork? No single human can do this job alone Error Reduction In every Why Teamwork? No single human can do this job alone Error Reduction In every complex environment studied, teams outperform individuals- including medicine! Improve patient Safety Reduce cost of error to the organization Job Satisfaction We will stay if we are supported by a team Increases morale and staff retention

Proven Training Techniques: Human Factors Skills that build teams, improve communication, reduce and trap Proven Training Techniques: Human Factors Skills that build teams, improve communication, reduce and trap the errors that will always occur • Briefings, Assertion, Situational Awareness Very trainable Measurable • Reduce accidents • Improve Staff Retention

Briefing Conversation involving all team members about the plan for the patient. Allows for Briefing Conversation involving all team members about the plan for the patient. Allows for – Patient plan of care – team to think through situations and anticipate complications – be ready with additional equipment, personnel, e. g.

When to Brief Start of work- Multidisciplinary Rounds New Team Members Pre- Procedure Change When to Brief Start of work- Multidisciplinary Rounds New Team Members Pre- Procedure Change in Situation

Structured Communication Situational Brief S-B-A-R: Situation Background Assessment Recommendation Structured Communication Situational Brief S-B-A-R: Situation Background Assessment Recommendation

Assertion Definition “Individuals speak up, and state their information with appropriate persistence until there Assertion Definition “Individuals speak up, and state their information with appropriate persistence until there is a clear resolution. ”

Assertion Model to guide and improve assertion in the interest of patient safety * Assertion Model to guide and improve assertion in the interest of patient safety *

Situational Awareness Definition Situational Awareness: An Overview A shared and accurate understanding of “what’s Situational Awareness Definition Situational Awareness: An Overview A shared and accurate understanding of “what’s going on” and “what is likely to happen next” Allows us to recognize events around us Act correctly when things proceed as planned React appropriately when they don’t SA is owned by the entire team, as with other Human Factors skills

Novice to Expert Skill Acquisition in Two Domains Technical Skills Novice Advanced Beginner Competent Novice to Expert Skill Acquisition in Two Domains Technical Skills Novice Advanced Beginner Competent Proficient Teamwork & Communication Skills Expert

Novice 3 -Person Team Situation Awareness 1 3 Shared Mental Model 2 Novice 3 -Person Team Situation Awareness 1 3 Shared Mental Model 2

Expert 3 -Person Team Situation Awareness Briefings and SBAR rapidly increase team members shared Expert 3 -Person Team Situation Awareness Briefings and SBAR rapidly increase team members shared mental model 1 Shared Mental Model 3 2

CRITICAL EVENT DRILLS: What are they? Lifelike Real time Normal noise - confusion - CRITICAL EVENT DRILLS: What are they? Lifelike Real time Normal noise - confusion - resources Situation must be diagnosed and managed by team exactly as in real life Real equipment and meds will be used You will be doing your usual job at all times

Key Crisis Management Skills Declaring emergency: SBAR • Early and clearly Leadership, optimal team Key Crisis Management Skills Declaring emergency: SBAR • Early and clearly Leadership, optimal team structure Attention allocation Task prioritization and distribution Effective, efficient resource use Clear orders, cross check and verification

CETT Simulation ONLY used as a training tool Video tapes erased Blame free, confidential CETT Simulation ONLY used as a training tool Video tapes erased Blame free, confidential training Don’t Share Scenarios! Please share your learnings

CRITICAL EVENT DEBRIEFING Debriefing #1 Rule Critique the performance. . . … not the CRITICAL EVENT DEBRIEFING Debriefing #1 Rule Critique the performance. . . … not the person What went well? …… Why? What could be better? ……Why? What systems’ problems did we find? What communication problems did we find? What teamwork glitches did we find?

“Take Home Message” You can become a great team If you practice, you will “Take Home Message” You can become a great team If you practice, you will get better Don’t cover flaws in the facility- fix them Ask to debrief your real critical events Have Fun! Let’s go meet our simulator

KPSims Simulation in Medicine KPSims Simulation in Medicine

Objectives g g Understand the importance of in-situ simulation to create expert teams and Objectives g g Understand the importance of in-situ simulation to create expert teams and test system Learn the components of a Critical Event Team Training

10 Years Ago. . . Simulation seemed like a really good idea! g There 10 Years Ago. . . Simulation seemed like a really good idea! g There was not much data supporting this g • Relied on faith in the experts • Trusted the instincts of our people Before the IOM report g Stanford Sim Center g • Wow! Where can we find $2 million? g University of Washington • A Modest Center, with great training taking place • “Help them become better, NOT worse”

High Risk Industries High Risk Industries

Simulation Questions How many times have you done a procedure and how recently? g Simulation Questions How many times have you done a procedure and how recently? g Do we teach hazardous procedures on real patients? g • Is this OK? Do our teams have to manage emergencies? g Do we learn from a near miss? Would our systems change? g This was all about supporting our people to do their best possible work, in a great system

Where should our educational efforts be focused? Simulation Training Where should our educational efforts be focused? Simulation Training

NCAL’s History of Simulation 2002 – In-situ simulation required element for Perinatal Patient Safety NCAL’s History of Simulation 2002 – In-situ simulation required element for Perinatal Patient Safety Project g 2004 - CETT T 3 trainings for perinatal domain g 2007 - One medical center across all domains • Trained over 200 CETT facilitators • 13 medical centers have monthly or quarterly CETT • Domains - Critical care, Perinatal, Periop, Pedi, Med-Surg & ED g

KPSims Collaborative 2007 - Grass roots effort to standardize scenarios and training g Develop KPSims Collaborative 2007 - Grass roots effort to standardize scenarios and training g Develop Regional P and P • Equipment handling and use • Standards for CETT Workshops • Qualifications of facilitators g Standardized and validated scenarios in six domains g

Critical Event Team Training ( CETT) Training Strategy g g g Training includes • Critical Event Team Training ( CETT) Training Strategy g g g Training includes • Human factors and team skills • Reality and types of Human Errors • Orientation to Simulator In-situ simulation training • Actual occurrences used as basis for scenarios • Focus on apparent system weaknesses • Situations where assessments & communication are important Blame free, confidential training

Standardized Regional CETT Train-the-Trainer 3 day Train-the-Trainer Program includes participation from all medical center Standardized Regional CETT Train-the-Trainer 3 day Train-the-Trainer Program includes participation from all medical center domains Must include physician leads g Nurse educators g Manager/Assist. managers g Front-line staff; RNs, RTs, CRNAs, CNMs g 20 -25 participants g

Simulation Scenarios Simulation Scenarios

No Technology g g g Standardized Patient: an “actor” who has coached to portray No Technology g g g Standardized Patient: an “actor” who has coached to portray a patient Role Playing: instructor and participant(s) are assigned specific “roles” Uses • Design of new workflows • Training workflows/communication skills – New staff/providers – Annual staff/provider training • Competency Assessments • Privileging

Hybrid Birthing Simulator Uses • Human Factors training • Skill-based/Task training • Team training Hybrid Birthing Simulator Uses • Human Factors training • Skill-based/Task training • Team training • Development of protocols and guidelines • Cultural change • Improved patient

Task Training Blue Phantom and Sim. Man Central Line Placement g Reasonably Hi-fidelity replication Task Training Blue Phantom and Sim. Man Central Line Placement g Reasonably Hi-fidelity replication of task g Realistic setting, or actual clinical area • In-Situ tests systems and processes supporting task g Objective, predetermined passing criteria • Training expectations • Standardized scoring sheets g Expert analysis of performance with immediate repetition of task

High Fidelity Simulators Ideal modality for team training Dynamic decision-making in stressful critical scenarios High Fidelity Simulators Ideal modality for team training Dynamic decision-making in stressful critical scenarios Uses Require use of critical equipment in a stressful environment Identify system issues which can impact performance Provide opportunity for part to execute skills taught in ACLS/PALS, etc.

KPSIMS The Practical Side of Running a CETT KPSIMS The Practical Side of Running a CETT

CETT Planning Team • Chief of Services • Nurse Managers • Nursing Services Director CETT Planning Team • Chief of Services • Nurse Managers • Nursing Services Director • Nurse Educators • House Supervisors • ACLS Instructor • NRP/PALS Instructor • Perinatal Safety Team • Med-Surg Safety Team • ED Team • Highly Reliable Surgical Team

First Steps in Planning CETT • Identify date – 3 -4 month lead-time – First Steps in Planning CETT • Identify date – 3 -4 month lead-time – Need to schedule conference room – Hold providers’ schedules • Identification of CETT objectives – What is the knowledge gap? – What is the ROI • Identification of participants – – Staff members RRT Responsibilities Grid, Code C grid, Shoulder dystocia grid Code Blue Roles and Responsibilities List of Team Members who need to participate

Team Roles & Positions 1 Airway Manager: Anesthesiologist/CRNA 2 Airway Assistant: RT draw ABGs Team Roles & Positions 1 Airway Manager: Anesthesiologist/CRNA 2 Airway Assistant: RT draw ABGs 6 Chest compressions 7 3 Bedside Nurse/Floor RN briefs team, IV, labs, dispense items, CPR Procedure MD chest tubes, ABG’s, etc. 4 Critical Care RN prepare drugs, defib. , ID & monitor rhythm 8 Recorder RN 5 Team Leader

Bab y. W arm Back Counter/Cupboards RN #C t/L e ck u (Circulate) Ba Bab y. W arm Back Counter/Cupboards RN #C t/L e ck u (Circulate) Ba B Ta ck bl e p. B a er gs a Pedi Team RN #B (Body) OBT Bo vie ion ct /Su OR Table RN #A (Airway) Anesthesia OR 1

Critical Events Team Training Morning Agenda Time 8: 00 a. m. to 8: 10 Critical Events Team Training Morning Agenda Time 8: 00 a. m. to 8: 10 a. m. Topic Welcome Review Objectives for the Day Presenter Physician lead CETT Team Trainers 8: 10 a. m. to 8: 50 a. m. “Turning a Team of Experts Team” into an Expert Team” Physician Lead CETT Team Trainers 8: 50 a. m. to 9: 00 a. m. Pre-Simulation Survey 9: 00 a. m. 9: 45 a. m. Simulation 1 9: 45 a. m. to 10: 15 a. m. Debrief for Simulation 1 Educator CETT Team Trainers Physician Lead CETT Team Trainers 10: 15 a. m. to 10: 30 a. m. Break 10: 30 a. m. to 11: 05 a. m. Simulation 2 11: 05 a. m. to 11: 45 a. m. Debrief for Simulation 2 11: 45 a. m. to 11: 55 a. m. Post-Simulation Survey 11: 55 a. m. to 12: 00 p. m. Closing Comments Physician Lead CETT Team Trainers Educator CETT Team Trainers Physician Lead CETT Team Trainers

Identify CETT Support Staff g Two local or regional instructors • Familiar with Simulators Identify CETT Support Staff g Two local or regional instructors • Familiar with Simulators g g g ACLS/PALS/NRP instructor Someone to identify and corral participants for each scenario Confederates e. g. Chief of Service, nurse manager/director, patient safety team member Scribe for debriefing recommend administration Manager to monitor patient workflow and notify patients

Few Weeks Prior to CETT Letter to CETT Attendees Critical Event Team Training Invitation Few Weeks Prior to CETT Letter to CETT Attendees Critical Event Team Training Invitation “Turning a Team of Experts into An Expert Team” You are invited to participate in Kaiser’s Critical Event Team Training (CETT) class. This class will equip you with strategies and skills that will help you to function on a team effectively. We will examine team communication & performance in the Med-Surg setting. Background. CETT resulted from teamwork observations made in acute care settings requiring proficient decision-making, action, and communication by individuals working together to achieve high quality clinical outcomes while minimizing avoidable adverse outcomes. Critical event team performance is highly visible in the obstetrical acute care settings at most hospitals; our Kaiser hospitals are no exception. However, team performance has only recently been. . .

Unique to Kaiser Permanente Roseville Women and Children’s Center • 12 days of testing Unique to Kaiser Permanente Roseville Women and Children’s Center • 12 days of testing prior to opening • All Staff run though drills Modesto Medical Center • CETT T 3 prior to opening Vacaville Outpatient Surgery • Maligent Hyperthermia Santa Clara- Testing of new cardiac cath and surgical capabilities • “ I couldn’t believe how much we found on the first day, and how much better we look now”

Unique Kaiser Opportunities Extraordinary Leadership from National and Regional Riskequipment, time and support Appreciation Unique Kaiser Opportunities Extraordinary Leadership from National and Regional Riskequipment, time and support Appreciation for systems- role of simulation in testing facilities, fixing systemic problems, training new teams, hospital and tech design Unified systems Increasing capability to track outcome data A remarkable cadre of dedicated trainers

Contacts Nancy Corbett RN, Regional Risk Management, Nancy. Corbett@kp. org, 510 987 -3575 g Contacts Nancy Corbett RN, Regional Risk Management, Nancy. [email protected] org, 510 987 -3575 g Jeff Convissar MD, National Risk Management, Jeff. L. [email protected] org, 510 271 -5719 g