WELCOME Thursday Plenary Four Common Conference Questions Wheres

WELCOME! Thursday Plenary

Four Common Conference Questions • Where’s the beef—or food, or coffee, or wi fi? • Where’s the DOD? • Where’s the slides? http: //www. teamsteppsportal. org/ • Where’s the conference next year?

Recognizing Our Debts My mom and baby niece Sue Sheridan

Team. STEPPS in Crisis Situations Timothy Adam, MBA Sheila Smyth-Giambanco, RN, MA, ACNS-BC Mark Mayes RN, MHA, CEN

Team. STEPPS in a Crisis Captain Tim Adam Master Trainer - Team. STEPPS

Team. STEPPS Where were you on September 11, 2001? Mod 1 05. 2 Page 6 TEAMSTEPPS 05. 2

Team. STEPPS Captain Jason Dahl Mod 1 05. 2 Page 7 TEAMSTEPPS 05. 2

Team. STEPPS United Airlines in a Crisis n All airline flight operations ceased for 3 days n 26% of United revenues gone n Financial, Public and Personal Crisis Mod 1 05. 2 Page 8 TEAMSTEPPS 05. 2

Team. STEPPS Leadership required the application of every principle and discipline of Crew Resource Management Mod 1 05. 2 Page 9 TEAMSTEPPS 05. 2

Team. STEPPS Fundamentals Used n Leadership n Communication n Team Structure n Situation Monitoring n Mutual Support n SBAR n CUS Words Mod 1 05. 2 Page 10 TEAMSTEPPS 05. 2

Team. STEPPS Flight Training in Crisis n 1972 - Miami, Florida n 1978 - Portland, Oregon n Review by NASA directed by Congress Mod 1 05. 2 Page 11 TEAMSTEPPS 05. 2

Team. STEPPS NASA Findings 1. Faulty Judgment 2. Poor Decision Making 3. Inadequate Communications 4. Poor Management 5. Poor Leadership Mod 1 05. 2 Page 12 TEAMSTEPPS 05. 2

Team. STEPPS CRM in Airline Training n United Airlines first to start CRM training in 1981 n By 1990 CRM implemented by all major air carriers n FAA: required CRM Training & Evaluation in 1990 n 6 generations of CRM Mod 1 05. 2 Page 13 TEAMSTEPPS 05. 2

Team. STEPPS Crew Resource Management has been proven to effectively change cultures of safety in the organizations that choose to adopt it Mod 1 05. 2 Page 14 TEAMSTEPPS 05. 2

Team. STEPPS Crew Resource Management Is Not n A quick fix to improve patient safety n A stand-alone system n A passive series of classroom lectures n A psychological or personality assessment tool n A way to control behavior by management Mod 1 05. 2 Page 15 TEAMSTEPPS 05. 2

Team. STEPPS Crew Resource Management Is Not Mod 1 05. 2 Page 16 TEAMSTEPPS 05. 2

Team. STEPPS What Crew Resource Management Is n A system that uses of ALL available resources n A system that promotes a non-punitive culture n A system that centers on clear, comprehensive Standard Operating Procedures (SOPs) Mod 1 05. 2 Page 17 TEAMSTEPPS 05. 2

Team. STEPPS Threat and Error Management (TEM) added in 1996 n Identifying potential Threats n Identifying potential Errors n Implementing steps to solve threats BEFORE they happen n Developing a TEM Safety Model Mod 1 05. 2 Page 18 TEAMSTEPPS 05. 2

Team. STEPPS What Would You Do? Mod 1 05. 2 Page 19 TEAMSTEPPS 05. 2

Team. STEPPS Threat and Error Countermeasures 1. Standard Operating Procedures 2. Checklist discipline 3. Team situational awareness 4. Quality briefings (Pre & Post) Mod 1 05. 2 Page 20 TEAMSTEPPS 05. 2

Team. STEPPS What is a Threat? Events or conditions which occur beyond the influence of the team; increase a situation’s complexity; and must be managed to maintain the margins of safety www. caas. gov Mod 1 05. 2 Page 21 TEAMSTEPPS 05. 2

Team. STEPPS Error Threat Mod 1 05. 2 Page 22 TEAMSTEPPS 05. 2

Team. STEPPS Six Categories of Threats 1. Environmental threats 2. 3. 4. 5. 6. Mod 1 05. 2 Page 23 Weather, Construction Organizational threats – Corporate, Regulatory Expected threats – Complex/risky procedure Unexpected threats - Power outage, Equipment malfunctions Latent (hidden) threats – Training, Hardware design Other threats - Stress, Fatigue, Distractions TEAMSTEPPS 05. 2

Team. STEPPS Unrecognized or mismanaged THREATS generate ERRORS Mod 1 05. 2 Page 24 TEAMSTEPPS 05. 2

Team. STEPPS What is an Error? An error is an action or inaction that leads to a different outcome than the crew expects. In other words… It is a MISTAKE Mod 1 05. 2 Page 25 TEAMSTEPPS 05. 2

Team. STEPPS Types of Errors 1. Procedural errors Not following SOPs 2. Handling errors n Improper system input 3. Communication errors n Mod 1 05. 2 Page 26 TEAMSTEPPS 05. 2

Team. STEPPS Communication Errors n Miscommunication n Misinterpretation n Incomplete Briefings n Non-Standard Phraseology n Incorrect information passed Mod 1 05. 2 Page 27 TEAMSTEPPS 05. 2

Team. STEPPS Words Or Phases That Can Mean Trouble n No problem, we can do that. n What's he/she doing now? n Is this safe? n Are you falling behind? n Are you rushed? n I’m concerned…this doesn’t look right to me. n Looking good! n I'm uncomfortable! n Hey…Watch this! Mod 1 05. 2 Page 28 TEAMSTEPPS 05. 2

Team. STEPPS What is Error Management? The process of detecting and responding to errors with countermeasures that mitigate the probability and/or severity of further errors or undesired states It is a PLAN Mod 1 05. 2 Page 29 TEAMSTEPPS 05. 2

Team. STEPPS We cannot PREVENT all errors Nor can we AVOID all errors - BUT We can MANAGE errors Mod 1 05. 2 Page 30 TEAMSTEPPS 05. 2

Team. STEPPS 5 Keys to Managing Errors 1. Follow established procedures 2. Use proper and consistent phraseology 3. Continuously monitor activity 4. Clarify / challenge inconsistencies 5. Make errors ‘visible’ (don’t hide them) Mod 1 05. 2 Page 31 TEAMSTEPPS 05. 2

Team. STEPPS Does all this really work? US Airways Flight 1549 – Hudson River Mod 1 05. 2 Page 32 TEAMSTEPPS 05. 2

Team. STEPPS Does all this really work? YES! It works in a crisis, and more importantly… It can PREVENT a crisis! Mod 1 05. 2 Page 33 TEAMSTEPPS 05. 2

Team. STEPPS THANK YOU! Tim Adam tjadam 777@aol. com Linked. In: http: //www. linkedin. com/in/tadam/ Master Trainer - Team. STEPPS Mod 1 05. 2 Page 34 TEAMSTEPPS 05. 2

Contingency Leadership during Crisis: Managing a Virtual and Satellite Clinic Post-Storm Sandy in NYC

Team. STEPPS World Trade Center Environmental Health Center: Survivor Program Mod 1 05. 2 Page 36 TEAMSTEPPS 05. 2

Team. STEPPS Who are we? n WTC Environmental Health Program is a program to evaluate and treat medical and mental health problems associated with the destruction of the WTC and the resulting spread of dust and fumes. n The Survivor program services the residents, students and local workers who lived or were in the area where the disaster occurred Mod 1 05. 2 Page 37 TEAMSTEPPS 05. 2

Team. STEPPS Training Background n Human Resources and WTC EHC Bellevue staff n n participated in ½ day Team. STEPPS Essentials for the clinic’s inter-professional team in July 2012 Focus was on strengthening communication and team building while providing care to vulnerable population Discussions focused on individual skill of situation monitoring and group skills of crossmonitoring with a “shared mental model” in place Tools practiced- brief, debrief, SBAR, huddle Conflict resolution – two challenge rule, Desc Script, CUS Mod 1 05. 2 Page 38 TEAMSTEPPS 05. 2

Team. STEPPS Summer 2012 “Growing Pains” n White Board for clinical staff to give “mental picture” of new patients and monitoring patients schedules so all knew where patients were and assured that all tasks were performed (lab, PFT, EKG, Xray, SW, MD, etc) n A. M. “Huddles” to review team roles, patient volume, challenges, events, expectations n Informal Briefs called when some event of an urgent nature arose n Debriefs employed at end of week to review how the week went, then briefed a plan for following week. SBAR encouraged but not formalized Mod 1 05. 2 Page 39 TEAMSTEPPS 05. 2

Team. STEPPS 9/11/12 Zadroga Bill Expansion brings new clinic challenges n Coverage extended to include over 50 cancers related to exposure of survivors/responders n National program for Survivors went “live” n NIOSH/Govt. programs face sequestering of funds due to budget crises and purse strings are tightened to be “LEAN” yet efficient Mod 1 05. 2 Page 40 TEAMSTEPPS 05. 2

Team. STEPPS “Superstorm Sandy” n The Anticipation Plan… “Deja Vue” n Lessons from Hurricane Irene 2011 n The Reality of Autumn, 2012 Mod 1 05. 2 Page 41 TEAMSTEPPS 05. 2

Team. STEPPS Aftermath of Sandy’s wrath… Mod 1 05. 2 Page 42 TEAMSTEPPS 05. 2

Team. STEPPS Evacuation post-storm Mod 1 05. 2 Page 43 TEAMSTEPPS 05. 2

Team. STEPPS Mod 1 05. 2 Page 44 TEAMSTEPPS 05. 2

Team. STEPPS WTC EHC “Our Huddle” n Bellevue closed, staff re-deployment plan in n n progress Temporary office space loaned to Clinical and Administrative team in WTC corporate offices at 125 Worth Street Roundtable reflections of storm, storytelling and self-care started our team discussions Brainstorming on “telephone triage” hotline setup , using SBAR to prioritize and “bucket” calls Borrowing “ creative space and resources” for clients needing urgent visits at our sister sites as interim plan during closure Mod 1 05. 2 Page 45 TEAMSTEPPS 05. 2

Team. STEPPS Contingency Leaders emerge… n Social workers fielded calls related to stress response, referred escalated or vulnerable clients to a mental health provider follow-up at satellite n WTC Clinic clerical staff became the “dispatch operators” taking the calls that came in at the Central Office toll-free hotline which was created in 4 languages by the team(Chinese, Russian, Spanish, English) n All calls logged onto Excel spread sheets with columns for documentation of responses, interventions and need for “closing the loop” debriefs at end of each day Mod 1 05. 2 Page 46 TEAMSTEPPS 05. 2

Team. STEPPS Our Virtual and Present Reality n Clinical Nurse Manager reviewed calls logged and priority coded into follow-ups: call-backs, prescription refills, urgent care appointments, emergency follow-ups, calls to new and former patients with concerns n Pulmonary MDs worked out a coverage schedule using the limited space offered at Gouveneur Hospital, PFT techs worked with their techs to meet needs of clients, Psychiatrist/Psychologist saw patients at high risk by appointments Mod 1 05. 2 Page 47 TEAMSTEPPS 05. 2

Team. STEPPS Other Team Roles n Patient Navigator- role became one of more “physical” navigation so WTC Bellevue patients would be able to find where they needed to go to be seen and receive care n WTC Clinic Administrator- became the “go to” for all the Gouv space and scheduling as well as resource allocation n Patient Care Associate(PCA) and pulmonary RN had multiple functions added onto roles in new space and had to immerse into existing team Mod 1 05. 2 Page 48 TEAMSTEPPS 05. 2

Team. STEPPS tools that helped n Brief n Debrief n SBAR and handoffs n Cross-monitoring * STEP (status of patient) * I’M SAFE (status of team member) Mod 1 05. 2 Page 49 TEAMSTEPPS 05. 2

Team. STEPPS Challenges n Time and space and resources n Volume of calls and limited resources n Maintaining Patient Safety by check-back of two identifiers n Maintaining HIPAA and documentation in the interim situation n Taking care of ourselves and each other as the results of the storm impacted staff and clients alike Mod 1 05. 2 Page 50 TEAMSTEPPS 05. 2

Team. STEPPS Our post-storm virtual and satellite clinic was a success… n Patients received their medications uninterrupted using pharmacy callbacks, access to EMR was not interrupted as both hospitals were on same network. n Temporary Access given to MD and Clinical RN Manager for Elmhurst network EMR as new patient referrals were made to this site and cancer coverage enrollment certifications weren’t delayed n Acute resp pts were seen, triaged and treated for their conditions which were exacerbated due to storm experiences Mod 1 05. 2 Page 51 TEAMSTEPPS 05. 2

Team. STEPPS Successes… n Mental Health services and crisis referral provided to our most vulnerable clients at satellite in Gouvenuer Hospital and Elmhurst site was prepared if any clients needed to transfer to their site n Team-building between our clinics staff who now were temporarily working together – standardization of PFT functions and competencies is one example of a positive outcome Mod 1 05. 2 Page 52 TEAMSTEPPS 05. 2

Team. STEPPS Lessons learned… n Planning is critical n Adaptability is essential n Every team member COUNTS n Every role is IMPORTANT n Give KUDOS to a job well done! n Chronicle the “Silver lining”stories Mod 1 05. 2 Page 53 TEAMSTEPPS 05. 2

Team. STEPPS “The first choice we make each and every day is “Will we act upon life, or will we be merely acted upon? ” Steven Covey Mod 1 05. 2 Page 54 TEAMSTEPPS 05. 2

Rapid response to tragedy in Aurora, Colorado Mark Mayes RN, MHA, CEN

Team. STEPPS Background n Aurora, Colorado n The Medical Center of Aurora Mod 1 05. 2 Page 56 TEAMSTEPPS 05. 2

Team. STEPPS ED – Trauma Center Mod 1 05. 2 Page 57 TEAMSTEPPS 05. 2

Team. STEPPS Aurora Theater Shooting July 20, 2012 Mod 1 05. 2 Page 58 TEAMSTEPPS 05. 2

Team. STEPPS Our Journey n Emergency Nurses Association n Beginning April 2011 n n n Mod 1 05. 2 Page 59 Site assessment & culture survey n Action planning Just-in-time training Real-time coaching and feedback Check-in calls Wrap up/Observation April 2012 TEAMSTEPPS 05. 2

Team. STEPPS Process Improvement �Leadership Development – ED Charge Nurses �Team Leader Role – Communication �Instant Communication �ED Surge / Diversion Mod 1 05. 2 Page 60 TEAMSTEPPS 05. 2

Team. STEPPS �Clear Role Definition �Charge Nurse & Charge MD �RRT Assignment Mod 1 05. 2 Page 61 TEAMSTEPPS 05. 2

Team. STEPPS Call a Huddle! ED Trigger List �Huddles • • • All ED beds are full ED SAFE change in status Pre Code/Trauma patient arrival > 5 M 1 holds in ED > 1 hour wait in the lobby > 2 ESI level 2’s in the lobby • Arrival of new physicians • Divert within our zone • Whenever you think we need one! Mod 1 05. 2 Page 62 TEAMSTEPPS 05. 2

Team. STEPPS Night of the Shooting �Under construction � 12: 38 shooting begins �Call at 12: 55 � 12 GSW by 01: 16 (Mode of arrival) Mod 1 05. 2 Page 63 TEAMSTEPPS 05. 2

Team. STEPPS Emergency Department n Huddles Several n Decon team n SBAR n Situation Monitoring n Team leaders n Brief and Debriefs n Mod 1 05. 2 Page 64 TEAMSTEPPS 05. 2

Team. STEPPS Emergency Department n Signs of success… n n Mod 1 05. 2 Page 65 Patient stories Bio Phone calls st n 1 call n How many can you take? TEAMSTEPPS 05. 2

Team. STEPPS Summary n Framework n Structure n Communication n Leadership n Mod 1 05. 2 Page 66 Let me get my charge nurse TEAMSTEPPS 05. 2