Using Simulation in Team STEPPS Training Simulation Objectives

Using Simulation in Team. STEPPS® Training

Simulation Objectives n To know and be able to apply the Event Based Approach to Training n To know and be able to develop Team. STEPPS training scenarios n To know and be able to develop Team. STEPPS performance measures n To know and be able to conduct effective debriefs of team performance Mod Page 1 205. 2 Page 2 TEAMSTEPPS 05. 2

Simulation Course Outline n Phase 1. Scenario Development n Exercise n Phase 2. Measurement Development n Exercise n Phase 3. Debriefing n Lessons Learned Mod Page 1 305. 2 Page 3 TEAMSTEPPS 05. 2

Simulation n Team skills are developed through practice and feedback n Simulation allows health care professionals to practice Team. STEPPS skills and strategies in a safe learning environment n Simulation includes Mod Page 1 405. 2 Page 4 n Role play n Part-task trainers n Human patient simulation n Standardized patients TEAMSTEPPS 05. 2

Simulation Keys to Success n Proper scenario design n n Focus on learning objectives Provide more than one opportunity to practice team behaviors n Accurate measurement n Include process and outcome measures n Capture behaviors n Debriefing n n Mod Page 1 505. 2 Page 5 Learning happens in the debrief Include feedback on how to improve performance TEAMSTEPPS 05. 2

Simulation Team. STEPPS Resources n Scenarios – Tab I n 131 Vignettes n Organized by department and Team. STEPPS skill and tool n Team Performance Observation Tool – Tab A, Appendix C Mod Page 1 605. 2 Page 6 n Tool for observing team performance n Observers should practice using the tool n Can be adopted to a particular type of care TEAMSTEPPS 05. 2

Simulation EBAT n Event-Based Approach to Training (EBAT) n Not n n a new method U. S. Navy, Targeted Acceptable Responses to Generated Events (TARGETs) (Fowlkes, Lane, Salas, Franz, & Oser, 1994) FAA Advisory Circular 120 -35 C § Line Operational Simulations § How to design simulation scenarios n Health n care domain Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) (Rosen, Salas, Silvestri, Wu, & Lazzara, 2008) Mod Page 1 705. 2 Page 7 TEAMSTEPPS 05. 2

Simulation Phase 1 n Scenario Development Mod Page 1 805. 2 Page 8 1. Specify teamwork skills 2. Define learning objectives 3. Choose clinical context 4. Define event sets 5. Define targeted responses TEAMSTEPPS 05. 2

Simulation Specify Teamwork Skills n Skills are general categories of behavior you want to train n Teamwork is too complex to train in a single scenario n Need to focus on a subset of competencies n There are four core skills in Team. STEPPS Mod Page 1 905. 2 Page 9 TEAMSTEPPS 05. 2

Simulation Define Learning Objectives n Learning objectives should be explicit and measurable n n Focus on specific Team. STEPPS behaviors Include the following information n Mod Page 1 10 05. 2 Page 10 Performance – Specifies the behavior Condition(s) – Specifies the conditions under which the behavior occurs Standards – Specifies the level of expected performance TEAMSTEPPS 05. 2

Simulation Example Objective Communication Learning Objective: Uses twochallenge rule or CUS to advocate for a patient in labor experiencing frequent, strong contractions Mod Page 1 11 05. 2 Page 11 TEAMSTEPPS 05. 2

Simulation Choose a Clinical Context Considerations n Medicine is a notoriously task-specific domain n Not all contexts are equal for training purposes n Choose a clinical context that affords opportunities to perform n Team. STEPPS provides 131 scenarios (Tab I) n Contexts should be appropriate for eliciting the team behavior of interest Mod Page 1 12 05. 2 Page 12 TEAMSTEPPS 05. 2

Simulation Team. STEPPS Scenario 86 Sally Rodgers, a 25 -year-old nullip in labor at term who is dilated 3 cm. This is a change from 2 cm over the previous 90 minutes. Sally is having frequent, strong to palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea, and begging her nurse for pain relief. The patient’s primary nurse believes epidural anesthesia would be appropriate and informs the obstetrician (OB) attending. The OB attending states he wants the patient to be dilated 4– 5 cm before she receives the epidural. The nurse reiterates to the attending OB that her assessment is that the patient is in active labor. Although Sally’s cervix has not demonstrated active labor yet, her nurse believes the pain relief and relaxation resulting from an epidural would be beneficial for the patient. The attending OB agrees to the epidural placement. The patient is fully dilated and begins pushing 3 hours after the placement. Mod Page 1 13 05. 2 Page 13 TEAMSTEPPS 05. 2

Simulation Clinical Context n Scenario 86 n Mod Page 1 14 05. 2 Page 14 Sally Rodgers, a 25 -year-old nullip in labor at term who is dilated 3 cm. This is a change from 2 cm over the previous 90 minutes. Sally is having frequent, strong to palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea, and begging her nurse for pain relief. TEAMSTEPPS 05. 2

Simulation Define Event Sets n Event sets are the building blocks of a scenario n Event sets consist of: n n Trigger – The incident to elicit the team behavior Distracters – Characteristics of the situation (i. e. , conditions) in which the behavior is to occur n Examples n Trigger: The OB attending states he wants the patient to be dilated 4– 5 cm before she receives the epidural n Mod Page 1 15 05. 2 Page 15 Distracter: Sally has a strong contraction and screams TEAMSTEPPS 05. 2

Simulation Define Targeted Responses n Targeted responses n Behavioral responses to each event set trigger n Expected levels of performance (i. e. , standards) n Example Mod Page 1 16 05. 2 Page 16 n Trigger: The OB attending states he wants the patient to be dilated 4– 5 cm before she receives the epidural n Response: The nurse uses two-challenge rule or CUS to advocate to the physician that Sally should receive pain medication now TEAMSTEPPS 05. 2

Simulation Guidance n Simulation scenarios should consist of 3 -5 event sets n n Provides more than one opportunity to demonstrate behaviors Creates reliability n Each event set should not include more than one trigger event n Event sets can be created by breaking a clinical procedure into chunks n Mod Page 1 17 05. 2 Page 17 Embed triggers into these chunks TEAMSTEPPS 05. 2

Simulation Trauma Example Pre-Hospital/Transport Trauma Phase Event Set Expected Team Behaviors Triggers Patient arrives without advance notice ("zero time") Leadership Team leader assembles team quickly Team leader advocates a plan Leadership Team leader advocates a plan based on known information Pre-Hospital/ Transport Mod Page 1 18 05. 2 Page 18 Inaccurate or incomplete information from EMS/rescue team Communication Team members use call-outs and checkbacks to share accurate patient injury information and discoveries through surveys Team members request information from EMS/rescue when information has not been provided TEAMSTEPPS 05. 2

Simulation Trauma Example Primary Survey Trauma Phase Trigger Expected Team Behaviors Leadership Team leader may ask non-team members to leave Too many people in room Primary Survey Equipment not working or is missing Mod Page 1 19 05. 2 Page 19 TEAMSTEPPS 05. 2 Communication Team members communicate findings and orders with clear call-outs and check-backs Team members are not distracted by others Situation Monitoring Team member identifies equipment issue Team member remedies issue (e. g. , replaces, fixes, or obtains needed equipment) quickly

Simulation Scenario Development n Select a scenario from the online menu n Identify/develop the following items n Team. STEPPS skill Learning objective(s) n Clinical context n Event set n n n Trigger and distracters Targeted responses n Be prepared to present your results Mod Page 1 20 05. 2 Page 20 TEAMSTEPPS 05. 2

Simulation Phase 2 n Develop Measures 1. Consider level of analysis 2. Clarify purpose 3. Decide what to measure 4. Select a measure Mod Page 1 21 05. 2 Page 21 TEAMSTEPPS 05. 2

Simulation Team Performance Observation Tool Leadership n Utilizes resources efficiently to maximize team performance n Balances workload within the team n Delegates tasks or assignments, as appropriate n Conducts briefs, huddles, and debriefs n Empowers team members to speak freely and ask questions Situation Monitoring n Includes patient/family in communication n Cross monitors fellow team members n Applies the STEP process when monitoring the situation n Fosters communication to ensure team members have a shared mental model Mod Page 1 22 05. 2 Page 22 TEAMSTEPPS 05. 2 Mutual Support Rating n Provides task-related support n Provides timely and constructive feedback to team members n Effectively advocates for the patient n Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict n Collaborates with team members Communication Rating n Provides brief, clear, specific, and timely information to team members n Seeks information from all available sources n Verifies information that is communicated n Uses SBAR, call-outs, check-backs and handoff techniques

Simulation Consider Level of Analysis n Individuals n MD n Nurse n Anesthesia n Teams n Delivery team n C-Section team n Multi-team – Team Structure Mod Page 1 23 05. 2 Page 23 n Core team n Contingency team n Administrative team TEAMSTEPPS 05. 2

Simulation Clarify the Purpose n Diagnose root causes of performance deficiencies n Identify specific weaknesses n Provide feedback n Relay information regarding strengths and weaknesses as a remediation plan n Assessment n Mod Page 1 24 05. 2 Page 24 Evaluate the level of proficiency or readiness TEAMSTEPPS 05. 2

Simulation Decide What to Measure n Outcomes tend to be more quantifiable and answer the question “What happened? ” n Processes answer the question “Why did it happen? ” Mod Page 1 25 05. 2 Page 25 TEAMSTEPPS 05. 2

Simulation Outcomes n Sometimes referred to as measures of effectiveness (MOEs) n Provide an indication of the extent to which the outcome of the task was successful Are important for most measurement purposes n What outcomes could we assess? n Mod Page 1 26 05. 2 Page 26 n Accuracy – Precision of performance (e. g. , correct medication) n Timeliness – How long (e. g. , time to incision) n Productivity – How much (e. g. , patient volume in ED) n Efficiency – Ratio of resources required versus used (e. g. , OR supplies) TEAMSTEPPS 05. 2

Simulation Processes n Sometimes referred to as measures of performance (MOPs) n Explain how and why certain outcomes may have happened (“Was the decision made right? ” versus “Was the right decision made? ”) n Important when diagnosing root causes of performance deficiencies and providing feedback or follow-on training n Types of Process Mod Page 1 27 05. 2 Page 27 n Procedural – Taskwork n Non-procedural – Taskwork n Teamwork TEAMSTEPPS 05. 2

Simulation Measurement Tips n Assess processes as well as outcomes when diagnosing performance deficiencies or providing feedback n Consider measuring at multiple levels to identify the weak link n Provide multiple opportunities to perform the same task or skill over the course of an exercise Mod Page 1 28 05. 2 Page 28 TEAMSTEPPS 05. 2

Simulation Select a Measure n Checklists n Consist of items/actions that have dichotomous answers such as Yes/No; Right/Wrong; Performed/Not Performed n Example: Primary Survey ABCs n Frequency counts n Indication of the number of times that a behavior, action, or error occurs n Example: Use of CUS, SBAR, Two-Challenge n Rating scales n Mod Page 1 29 05. 2 Page 29 Numerical or descriptive judgment of how well a task was performed TEAMSTEPPS 05. 2

Simulation Checklist Tips n Best used with a scripted scenario versus “free play” n Items should be related to triggers embedded into the scenario n Each item should represent a single action taken by the individual, team, or battlegroup n Label or define the response category that you are using Mod Page 1 30 05. 2 Page 30 TEAMSTEPPS 05. 2

Simulation Checklist Action/Behavior Assess Airway Breathing Circulation/FAST Exam Disability Exposure and Environment Mod Page 1 31 05. 2 Page 31 TEAMSTEPPS 05. 2 Yes No

Simulation Frequency Count Tips n Frequency counts are better when measuring acts of commission than acts of omission n Overt actions or errors versus failing to demonstrate a particular behavior n Frequency counts are good when you want to know how often a specific action is taken or task is performed n Frequency counts can be recorded during a critical event in an exercise or throughout the entire scenario Mod Page 1 32 05. 2 Page 32 TEAMSTEPPS 05. 2

Simulation Frequency Count Positive Instances Communication Check-back Call-outs SBAR Unintelligible Communications Mutual Support Positive Instances Two-Challenge CUS Task Assistance Mod Page 1 33 05. 2 Page 33 TEAMSTEPPS 05. 2

Simulation Graphic Rating Scale 1. The team leader assigned roles to the Trauma Team. Ineffective 1 2 x 3 Very Effective 4 5 6 2. The PGY 2 used check-back to confirm orders. Strongly Disagree 1 Mod Page 1 34 05. 2 Page 34 x 2 3 TEAMSTEPPS 05. 2 4 5 Strongly Agree 6

Simulation Anchored Rating Scale Communication: Used check-back during trauma resuscitation. 1 2 3 4 Did not use check - back Used checkback once to confirm care plan at end of case Used checkback to confirm all medication orders Used checkback to confirm critical orders, primary and secondary survey Mod Page 1 35 05. 2 Page 35 TEAMSTEPPS 05. 2 x 5 Used checkback to confirm all critical orders

Simulation Rating Scales n Uses n n n Rating scales are good for assessing quality when it does not equate to a sum of quantity Rating scales are good for assessing tasks that are less procedural in nature Rating scales are better to use when you are evaluating performance on a continuum n Tips n n Mod Page 1 36 05. 2 Page 36 Define or clearly describe what you are measuring Include a specific stem or item to accompany the rating scale TEAMSTEPPS 05. 2

Simulation Measures Develop a measure to assess performance for the scenario you developed earlier Be prepared to present your measures Mod Page 1 37 05. 2 Page 37 TEAMSTEPPS 05. 2

Simulation Phase 3 n Debriefing Mod Page 1 38 05. 2 Page 38 1. Introduce the debrief process 2. Describe what happened 3. Conduct an analysis of performance 4. Identify lessons learned TEAMSTEPPS 05. 2

Simulation Description Phase n Recap of what happened in the scenario n Team members share their perspectives on what occurred during the scenario and reach common ground n This helps ensure everyone takes away similar lessons from the experience n How measurement can help n Provides a structure for understanding the scenario n n Focus on critical aspects of performance n Mod Page 1 39 05. 2 Page 39 The event sets or behavior categories can be used to structure discussion Helps to keep the discussion focused on events relevant to the learning objectives TEAMSTEPPS 05. 2

Simulation Analysis Phase n A systematic investigation of why things happened in the scenario as they did n The team focuses on understanding what went well and what could have been done better n How measurement can help n Can help compare the team’s performance with standards of performance n Mod Page 1 40 05. 2 Page 40 Were the Team. STEPPS behaviors performed when necessary? If so, were they performed correctly or could they be improved? TEAMSTEPPS 05. 2

Simulation Application/Generalization Phase n A look ahead to how the team can generalize what they learned in the scenario to their daily practice n The team generates lessons learned and discuss what needs to be corrected and how to correct it n How measurement can help n Explicit event sets can be used to draw parallels between the scenario and the actual clinical environment n Explicit measures associated with these events help promote reflection about how to transfer what went well to the actual clinical environment Mod Page 1 41 05. 2 Page 41 TEAMSTEPPS 05. 2

Simulation Tip for Success 1 n Tip 1: Don’t overwhelm learners or observers — Keep it simple n People can integrate only a few key learning points from a scenario n Observers have a limited attention span and frequently have to multi-task. Don’t ask too much; you won’t like what you get n Rule of thumb: Have a key event every 1 to 2 minutes of scenario time Mod Page 1 42 05. 2 Page 42 TEAMSTEPPS 05. 2

Simulation Tip for Success 2 n Tip 2: Telling someone how well they did is not good enough n They need diagnostic feedback n Specific n Behaviorally focused n Descriptive Mod Page 1 43 05. 2 Page 43 TEAMSTEPPS 05. 2

Simulation Tip for Success 3 n Tip 3: Train observers n Training, by definition, is systematic. For measurement to guide this process, it too must be systematic, reliable, and valid n Make sure everyone has common expectations about performance n Develop and use a scoring guide Mod Page 1 44 05. 2 Page 44 TEAMSTEPPS 05. 2

Simulation Rater Scoring Guide Communication Team Behaviors SBAR – uses structured communication (situation, background, assessment, recommendation) Call-out – verbalizes critical information to the entire team Check-back – uses closed-loop communication Mod Page 1 45 05. 2 Page 45 Hit all components (situation, background, assessment, and recommendation) are present Variation in Quality several, but not all components were used (e. g. , the situation was presented and the background leading to the situation was stated, BUT NO assessment or recommendation is provided) a team member critical information was clearly verbalizes only verbalized to one of critical information to the team members and not all team members all of them a sender initiated a a team member initiates message, the communication and the receiver accepted other team member the message and provides verification of provided feedback receipt and understanding, confirmation, and but the initiator DOES NOT the sender verified verify this understanding is TEAMSTEPPS 05. 2 message was correct. Miss structured communication was NOT used at all when appropriate (e. g. , during a handoff) critical information w not verbalized a sender initiated a message but the receiver DID NOT provide feedback confirmation, and the sender did not verify message was receiv

Simulation Tip for Success 4 n Tip 4: Keep teamwork and clinical skills separate n Use “dual debriefs” n n n Correct an individual’s major clinical deficiencies in a follow-up session Don’t overcomplicate the clinical nature of the scenario when your main purpose is to train teamwork n n Mod Page 1 46 05. 2 Page 46 Provide feedback on teamwork skills as a team Teamwork novices especially should be given the chance to focus on teamwork in the scenario, not complex clinical issues As the team members’ teamwork skills advance, more complex clinical scenarios can be used TEAMSTEPPS 05. 2

Simulation Tip for Success 5 n Tip 5: Event-based methods involve more than just measurement n Good training design practices n Good scenario design practices n Good debrief facilitation practices Mod Page 1 47 05. 2 Page 47 TEAMSTEPPS 05. 2

Simulation Teamwork Actions n Apply the Event Based Approach to Training n Able to develop Team. STEPPS training scenarios n Able to develop Team. STEPPS performance measures n Know how to conduct effective debriefs of team performance Mod Page 1 48 05. 2 Page 48 TEAMSTEPPS 05. 2