Implementation Guide, 2

TeamSTEPPS® Long-Term Care Version

Keys to success at each phase include involvement of the right people, use of information-driven decision making, and careful planning before acting. The following paragraphs provide an overview of each of the phases including goals and objectives, key actions, and recommended tools and resources.

 

The Ten Steps of Action Planning

Step 1. Create a Change Team

Objective:  To assemble a team of leaders and staff members with the authority, expertise, credibility, and motivation necessary to drive a successful TeamSTEPPS Initiative.

Key Actions:

  • Select a multidisciplinary Change Team.
  • Ensure representation from three different leadership levels: Senior Leadership, Clinical/Technical Expertise, and Frontline Leadership (go to Step 1 Worksheet).
  • Ensure that at least one member is very knowledgeable of team strategies, tools, and training techniques.
  • Ensure that at least one member has experience in process improvement, including performance trending techniques. Relevant skills include data collection, analysis, and presentation.

Tools and Resources:

  • Step 1 Worksheet - Creating a Change Team: Key Characteristics and Primary Roles of Essential Members.

Tips for Success:

  • The Change Team will focus on improving processes within its own clinical workspace. Choose members with relevant clinical expertise, workplace location, credibility, and direct involvement in the processes that will be affected by the TeamSTEPPS Intervention.
  • Ideally, all Change Team members will attend team training.
  • Optimal Change Team size is five or six individuals.
  • Involvement of the interdisciplinary team is essential.

The Change Team then proceeds through Steps 2 to 10.

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Step 2. Define the Problem or the Opportunity for Improvement

Objective:  To specifically state the problem, challenge, or opportunity for improvement that will be targeted by your TeamSTEPPS Intervention and to identify the involved process. What is it specifically that you want to "fix" or improve?

Key Actions:

  1. Identify a problem, challenge, or opportunity for improvement that you feel could be bettered with enhanced resident care teamwork. Strategies include:
    • Reviewing workspace performance and safety data such as incident reports, the AHRQ Patient Safety Culture Survey, the Team Assessment Questionnaire, the Team Performance Observation Tool, and site-specific process and outcomes measures.
    • Reviewing reports of root cause analyses.
    • Asking frontline staff, "What are bad outcomes waiting to happen because of breakdowns in the transfer of critical information?" "What are the things that keep you up at night?"
  2. Identify the process during which the problem, challenge, or opportunity occurs by stating what the process is, who is involved, and when and where it occurs.

Example of a Problem Definition

1. Identify the problem: Suboptimal telephone communication of resident information between subacute and long-term care unit staff members.
2. Identify the clinical process:
    What: Telephone communication of resident information
    Who: Communication from staff subacute nurses to medical staff (physicians/PAs/APRNs)
    When: During normal daily operations
    Where: On the subacute unit

Tools and Resources:

These tools may be used to identify problems and to provide baseline data for measuring the effectiveness of a TeamSTEPPS Intervention.

  • AHRQ Patient Safety Culture Survey.
  • Team Assessment Questionnaire.
  • Team Performance Observation Tool (requires an observer trained in resident care teamwork).
  • Staff and/or resident satisfaction surveys.

Tips for Success:

  • Change Teams may want to define three or four problems/opportunities and then select the highest priority for the TeamSTEPPS Intervention.
  • Look for problems/opportunities that meet the following criteria:
    • The associated process occurs frequently.
    • Breakdowns in team performance could result in harm to residents.
    • Process change is feasible and likely within the short term.
  • Administer the AHRQ Patient Safety Culture Survey and/or the Team Assessment Questionnaire prior to conducting resident care team training or implementing your TeamSTEPPS Intervention. The results will provide some of the baseline data needed for testing the effectiveness of the intervention.

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Step 3. Define the Aims of Your TeamSTEPPS Intervention

Objective:  To succinctly state in measurable terms exactly what you hope to achieve with the TeamSTEPPS Intervention — what will be achieved, who will be involved, and when and where the change will occur.

Key Actions:

  1. Develop one to three measurable aims for your TeamSTEPPS Intervention, and state in one or two sentences what you hope will be achieved, who will be involved, and when and where the improvements will occur. Aims can be based on the process of the TeamSTEPPS Intervention itself or on the outcomes of that intervention.
    • Team process aims focus on how well or often your staff carries out your TeamSTEPPS Intervention.
    • Outcome aims focus on changes that occur because your staff carries out the intervention. These aims can be directed at changes in team performance (team outcome aims) or in clinical results (clinical outcome aims).
    • It is ideal (but not necessary) to have a team process aim, a team outcome aim, and a clinical outcome aim. This becomes particularly important when testing the effectiveness of your TeamSTEPPS Intervention.

Example of Process and Outcome Aims

The Problem: Suboptimal telephone communication of resident information from subacute nurses to medical staff (MDs/PAs/APRNs).
Team Process Aims:
  1. Increase the percentage of subacute nurses and medical staff who receive training on SBAR to at least 80 percent within 1 month of resident care team training implementation.
  2. Increase the use of SBAR by nurses during telephone communications to medical staff by at least 60 percent within 2 months of TeamSTEPPS Intervention implementation.
Team Outcome Aim: Increase the perception among all subacute staff of good team behavior, as assessed by the Team Assessment Questionnaire, within 6 months of TeamSTEPPS Intervention implementation.
Clinical Outcome Aim:Increase the medical staffs� average rating of the quality of subacute nurses� telephone communication of resident information by at least 50 percent within 3 months of TeamSTEPPS Intervention implementation.

Tools and Resources:

  • Step 3 Worksheet

Tips for Success:

  • Develop aims that specifically address the target problem identified during Step 2.
  • Put time and thought into defining the problem and defining the aims of your TeamSTEPPS Intervention since they are the most important steps in action plan development. The target problem and stated aims drive the development of all remaining components of the action plan.

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Step 4. Design a TeamSTEPPS Intervention

Objective:  To design a TeamSTEPPS Intervention that will address your targeted problem or challenge and achieve your stated aims.

Key Actions:

To design your TeamSTEPPS Intervention you will use process improvement techniques and systems-based strategies for human error reduction. The following key actions should be performed in the order they appear:

  1. Flowchart or map the process during which the target problem/challenge/opportunity occurs. Write down the process steps as they currently occur and identify who is doing what, when, with what tools.
  2. Study the process to identify risk points where things could go wrong and lead to a recurrence of the target problem/challenge/opportunity.
  3. Identify where in your process team strategies and tools might eliminate or mitigate the risk points and prevent the problem from recurring.
  4. Determine which team tools and strategies, such as brief, huddle, debrief, STEP, SBAR, and I PASS the BATON, would work best to eliminate the process risk points. Strategies include:
    • Brainstorming with Change Team members and other front-line staff.
    • Eliciting input from teamwork experts.
    • Reviewing the evidence base and searching for best practices.
  5. Draft your TeamSTEPPS Intervention. State what team tools and strategies will be implemented, who will use them, and when and where they will be used.
  6. Evaluate your TeamSTEPPS Intervention for potential benefits and negative effects:
    • Flowchart the redesigned process as you imagine it will look with your TeamSTEPPS Intervention in place.
    • Identify potential failure points in the redesigned process. How will you reduce the probability and/or severity of these failures?
    • Identify potential benefits and negative effects of the redesigned process on units outside your workspace. How will you control potential negative effects?
  7. Evaluate your TeamSTEPPS Intervention using the TeamSTEPPS Intervention Checklist, and modify your intervention based on the results.
  8. Write a detailed description of your final TeamSTEPPS Intervention. State what team tools and strategies will be implemented, who will use them, and when and where they will be used.

Tools and Resources:

  • Step 4 Worksheet.
  • TeamSTEPPS Intervention Checklist.
  • Godfrey M, Nelson E, Batalden P, et al. Clinical Microsystems Action Guide. Hanover, NH: Trustees of Dartmouth College; 2004 (available at www.clinicalmicrosystems.org )—For tools and techniques for clinical process mapping and flowcharting and for brainstorming.
  • Almeida SA, Almeida PA. A Primer for Patient Safety: Evidence-Based Requirements, Standards, and Recommendations for Program Development and Implementation, Third Edition. (Prepared under Contract No. GBR-04-USUHS-2002-001). Bethesda, MD: Uniformed Services University of the Health Science; March 2006.—For concise summaries of evidence-based patient safety program requirements, standards, and recommendations from the Department of Defense (DoD), The Joint commission, and leading government and private sector resident safety expert groups. (This information is available for DoD use only.)

Tips for Success:

  • Stay focused on your target problem and your stated aims. While designing the intervention, keep asking, "How will it solve the problem? How will it achieve our aims?"
  • Elicit input from the entire Change Team and from other key personnel such as leaders, clinicians, frontline staff, subject matter experts, and personnel most affected by the improvement effort.
  • Keep it simple. Ideally, address one problem — one process — one team tool. Your intervention will have a greater probability of success if you implement smaller changes, but do it very well.

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Step 5. Develop a Plan for Testing the Effectiveness of Your TeamSTEPPS Intervention

Objective:  To develop a method to determine if your TeamSTEPPS Intervention achieved your aims. Did it work?

Key Actions:

Ideally, you will test if your TeamSTEPPS Intervention achieved each one of the aims you generated during Step 3. If time and resources are limited, select only one aim for testing. Base your selection on the importance of the aim and on the feasibility of testing it. Testing does not need to be complicated. Basic performance improvement trending and tracking methods generally suffice. For each aim you select, create a testing method by performing the following key actions:

  1. Identify who on your Change Team will be responsible for data collection, analysis, and presentation (generation of graphs and charts).
  2. Identify a measure and define target ranges for that measure.
    • The measure should answer whether you achieved your aim.
  3. Create a study design.
    • The most common study design for clinical process improvement is a simple pre- and post-intervention study. With this design, you (1) gather your data before implementation of your TeamSTEPPS Intervention, then (2) implement the intervention, then (3) gather the same data again at predetermined time intervals after implementation of the intervention, and (4) compare the results from your preintervention data to those of your postintervention data. The data you collect before implementation of your intervention is known as your baseline data or control group data.
  4. Select "test subjects" or data source.
    • For measures that assess team process or team outcomes, your "test subjects" generally are your staff members whom you want to use the team tools — for example, the nurses who will use SBAR for telephone communication of resident information to physicians. For measures that assess clinical outcomes, common data sources are resident health records or existing health care quality improvement databases.
  5. Identify a comparison or "control" group.
    • The control group is a group of individuals, similar in characteristics to the intervention group, who do not receive the intervention. To demonstrate the effect of your intervention, you must apply your measures to both a control group and an intervention group and then compare the results. Differences between the groups show the effect of your intervention.

    (Note: For the pre- and post-intervention study design described above, the preimplementation data serve as the control).

  6. Determine methods for data collection.
    • Determine who will collect the data, when, where, and how.
  7. Determine methods for data analysis and interpretation.
    • You may start by doing simple counts of your target events or clinical outcomes and displaying these counts on a line graph by day, week, or month. An example of counts includes number of times nurses use SBAR for telephone communication of resident information to physicians. However, to show true change over the test period, you will need to consider "denominator data" or the number of times the event could have occurred. Rates (reported as percentages) are simple data calculations that account for denominator data. Rates are calculated by dividing the number of events that did occur by the total number of opportunities for the event to occur. To assess the effectiveness of your intervention using a rate: (1) calculate the rate at baseline before conducting your resident care team training or implementing your intervention; (2) calculate the same rate again after implementing your intervention; and (3) compare the pre- and post-intervention rates to determine any changes due to your intervention.

Example of Process and Outcome Measures Using Rates

Team Process MeasureClinical Outcome Measure
Number of times nurses used SBAR for telephone communication of resident information to physicians/Total number of times nurses communicated resident information by telephone to physicians= Rate of Nurse Telephone SBAR UsageNumber of residents admitted to subacute unit who incurred an adverse event or near miss/Total number of residents admitted to subacute unit= Rate of subacute adverse and near miss events

Statistics Tip: Choose measures that will likely result in at least 30 events (or cases) in your numerator within the timeframe of your study.

  • Another simple data calculation is time-to-event-occurrence, or the elapsed time from a defined starting point to the occurrence of a specific event. This measure is particularly useful for clinical processes that should occur within a limited period of time. An example includes the duration of time between a resident admission and evaluation by a physician.
  • Survey scores are a third easy-to-use group of measurements. To assess the effectiveness of your intervention using a survey score: (1) administer the survey at baseline, before conducting your resident care team training or implementing your intervention; (2) administer the same survey again after implementing your intervention, preferably to the same people; (3) calculate the scores for the pre- and post-intervention surveys; and (4) compare the scores from the two groups. You may use already developed surveys such as the AHRQ Patient Safety Culture Survey, the Team Assessment Questionnaire, or existing resident or staff satisfaction surveys. Or, you may develop simple surveys of your own.

Examples of Process and Outcome Measures Using Survey Scores

Team Process MeasureTeam Outcome MeasureClinical Outcome Measure
The frequency of use of SBAR by nurses for telephone communication of resident information to physiciansSubacute clinical staff's perception of resident care team behavior — as measured with the Team Assessment QuestionnairePhysicians' perception of the quality of telephone communication of resident information by nurses—as assessed using a 5-point Likert scale
  • For each of these surveys, your goal would be to find an increase in the scores after implementation of your TeamSTEPPS Intervention.
  • To learn about Likert scales, go to http://en.wikipedia.org/wiki/Likert_scale .
  1. Determine data presentation method.
    • Determine how you will visually display your results to show that you achieved your aims.
    • Simple line graphs, run charts, and bar graphs are usually very effective. Control charts provide more information but require more skill to generate.
  2. Determine resources required (time, equipment, personnel, expertise).
  3. Determine timelines for the test
    • For baseline data: When will you collect it, analyze it, and display it?
    • For post-implementation data: When will you collect it, analyze it, and display it?

Tools and Resources:

  • Step 5 Worksheet.
  • Team Performance Measurement Tools: AHRQ Patient Safety Culture Survey, Team Assessment Questionnaire, Team Performance Observation Tool (requires an observer trained in resident care teamwork).
  • The Joint Commission. Tools for Performance Measurement in Health Care: A Quick Reference Guide. Oakbrook Terrace, IL: Joint Commission Resources; 2002.
  • Godfrey M, Nelson E, Batalden P, et al. Clinical Microsystems Action Guide. Hanover, NH: Trustees of Dartmouth College; 2004. (Available at www.clinicalmicrosystems.org)
  • Institute for Healthcare Improvement Web site (free tools and tutorials). (Available at www.IHI.org .

Tips for Success:

  • Keep it simple. Select one solid measure for each aim.
  • Ideally you will have one team process measure, one team outcome measure, and one clinical outcome measure. The team process measure will assess whether your staff actually carried out your TeamSTEPPS Intervention. For example, how often did your nurses use SBAR for telephone communication of resident information to physicians? The team process measure becomes particularly important if your outcome measures show no improvement with your intervention. Failure to show improvement in team performance or in clinical outcomes may be due to the staff's failure to implement the intervention and NOT to the ineffectiveness of the intervention itself.
  • If you will use any resident data, ensure that your plan adheres to all resident rights and privacy laws and regulations. Check with your governing Institutional Review Board, Committee for the Protection of Human Subjects, or other resident subject matter expert if you are unsure.
  • Use existing data sources whenever possible. Determine what data your facility or workspace already collects that you may be able to use.

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Step 6. Develop an Implementation Plan

Objective:

Part A: To develop a plan for training your staff in the resident care teamwork knowledge and skills required to successfully implement your TeamSTEPPS Intervention.

Part B: To develop a plan for putting your TeamSTEPPS Intervention into place.

Part A: Develop a Plan for Resident Care Team Training

Before implementing your TeamSTEPPS Intervention, you will need to provide resident care team training to staff members and other personnel who will be involved in the intervention. It is not necessary to train all staff on all teamwork concepts and tools. Identify what your staff needs to know in order to make your TeamSTEPPS Intervention successful, and then select the TeamSTEPPS training materials and techniques that best meet your specific training requirements. Complete the following key actions to develop Part A of your implementation plan.

Key Actions:

  1. Identify your trainee audiences and their training requirements.
    • Determine who (staff members within a targeted unit/department) needs to be trained on what resident care teamwork knowledge/skills and by when.
  2. Identify the instructors for each audience.
  3. Develop a training plan for each audience, including:
    • Who will attend the training sessions.
    • What team knowledge and skills you will teach.
    • When the training sessions will occur and for how long.
    • Where the sessions will occur.
    • How you will train (method of presentation, tools, supplies.)
    • Logistics such as schedules, equipment, impact of training on other operations, additional resources required, and ways to notify trainees and other key stakeholders.
  4. Determine if any of your audiences will require refresher training. If so, repeat the above actions for refresher training.
  5. Create your training timelines.
    • Include time for developing your materials and managing logistics.
    • Include initial, newcomer, and refresher training, if needed.

Part B: Develop an Implementation Plan for the TeamSTEPPS Intervention

Key Actions:

Part B of the implementation plan addresses how you will put your TeamSTEPPS Intervention into place. Complete the following key actions:

  1. Identify person(s) responsible for implementation.
  2. Determine how you will implement the TeamSTEPPS Intervention in order to achieve your aims.
    • Who will use what team strategies and tools, when, and where?
    • Will they need additional resources to implement the intervention?
  3. Develop an implementation timeline.

Tools and Resources (for Part A and Part B):

  • Step 6 Worksheet.
  • TeamSTEPPS Training Techniques.

Tips for Success:

  • Consider pilot testing both your resident care team training and your intervention implementation plans with a small group prior to implementing the programs on a larger scale.
  • Consider establishiing a TeamSTEPPS Learning Action Network for followup and information sharing. This would involve scheduled conference calls with sites that have implemented an Initiative. Calls are best held either bi-monthly or quarterly.

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Step 7. Develop a Plan for Sustained Continuous Improvement

Objective: To develop a plan for continuous process improvement with your TeamSTEPPS Intervention, including plans for ongoing assessment of the effectiveness of the intervention, sustainment of positive changes, and identification of opportunities for further improvement.

Key Actions:

  1. Develop a plan for monitoring over time the effectiveness of your TeamSTEPPS Intervention.
    • The purpose of the monitoring plan is two-fold — to determine if your intervention continues to achieve your aims and to identify opportunities for further process improvement.
    • Designing a monitoring plan is similar to designing a testing plan (Step 5). The monitoring plan is often just a simplified version of the testing plan, with fewer and less frequent measurements. For your monitoring plan, determine:
      • Measures and target outcomes.
      • Test subjects and/or data source (e.g., existing Quality Improvement [QI]database).
      • Methods for data collection.
      • Methods for data analysis and interpretation.
      • Resources required (money, time, equipment, personnel, expertise).
      • Person(s) responsible for implementation and oversight.
  2. Determine how data from your monitoring plan will be used to continually improve processes and performance.
  3. Develop a plan for sustaining and spreading positive changes.
    • Consider a recognition and rewards program.
    • Develop a plan for timely continuous feedback on performance and for sharing lessons learned.
    • Determine how you will monitor teamwork behavior and provide on-going teamwork coaching.
    • Consider how you will spread positive changes to other workspaces or to other processes within your workspace.

Tools and Resources:

  • Step 7 Worksheet.
  • Massoud MR, et al. A Framework for Spread: From Local Improvements to System-wide Change. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org .)
  • 100,000 Lives Campaign. Running a Successful Campaign in Your Hospital, How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org .)
  • 100,000 Lives Campaign. Getting Started Kit: Sustainability and Spread, How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org .)

Tips for Success:

  • Integrate your TeamSTEPPS Intervention into existing processes for long-term sustainment. Make it part of your workspace's normal daily routines. Examples of integration include (a) incorporating team principles into staff meetings, QI committees, and medical staff meetings; and (b) integrating monitoring measures into existing workspace databases and systems.
  • Publicize your successes. Examples include visibly displaying large wall charts in your workspace showing positive performance trends; writing articles in local publications and medical and professional journals; and giving presentations on your results at staff meetings and other professional health care meetings.
  • Develop standardized procedures for integrating newly acquired staff.

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Step 8. Develop a Communication Plan

Objective: To create a communication plan targeting major stakeholders that will generate initial and ongoing support for the TeamSTEPPS Initiative and promote the maintenance and spread of positive changes.

Key Actions:

  1. Identify your stakeholders.
    • Whose support will be important for achieving the aims of your intervention and for maintaining positive changes?
    • Consider nursing home leaders, frontline leaders, staff directly involved in the intervention, residents, families, support staff, and other units affected by the intervention.
  2. For each of your identified stakeholder groups, develop a communication plan, including:
    • Goals for communication with this group. What do you want to achieve?
    • Who will get the information.
    • What information you will communicate.
    • When and how often you will communicate.
    • How you will communicate (e.g., reports, presentations, e-mails).
  3. Identify a person on the Change Team who will be responsible for implementation and oversight of the communication plan.

Tools and Resources:

  • Step 8 Worksheet.

Tips for Success:

  • Stay focused on your goals for communication with each stakeholder group. Keep asking, "What do I hope to accomplish for the initiative (e.g., buy-in, resources, participation) by communicating with this group?" The goals will drive the development of your communication plan.

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Step 9. Putting It All Together: Write the TeamSTEPPS Action Plan

Objective: To generate a written action plan, based on Steps 1 through 8 that will function as your "How-To Guide" for every component of your TeamSTEPPS Initiative.

Key Actions:

If you completed each of the worksheets for Steps 1 through 8, you have already written your TeamSTEPPS Action Plan. Ensure that your final action plan includes all the following elements:

  1. Identification of the Change Team.
  2. Identification of the problem, challenge, or opportunity for improvement that will be the focus of the TeamSTEPPS Initiative.
  3. Stated aims of the TeamSTEPPS Intervention.
  4. Detailed description of the TeamSTEPPS Intervention.
  5. A plan for testing the effectiveness of the TeamSTEPPS Intervention.
  6. An implementation plan for both resident care team training and for the TeamSTEPPS Intervention.
  7. A monitoring plan for ongoing assessment of the effectiveness of the TeamSTEPPS Intervention.
  8. A communication plan to generate support for the TeamSTEPPS Initiative, to keep major stakeholders informed of progress, and to maintain and spread positive changes.
  9. Timelines.
  10. Resources required.

Tools and Resources:

  • Step 1 through 8 Worksheets (You have already created your customized TeamSTEPPS Action Plan by completing Step 1 through 8 worksheets.)
  • Kotter J, Rathgeber H. Our Iceberg Is Melting. Changing and Succeeding Under Any Conditions. New York, NY: St. Martin's Press; 2006.

Tips for Success:

  • Save your original step worksheets. They may contain information and ideas you might want later.

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Step 10. Review Your TeamSTEPPS Action Plan With Key Personnel

Objective: To generate support and elicit ideas from major stakeholders, and to identify barriers to program implementation.

Key Actions:

  1. Identify stakeholders who could contribute significantly to the action plan. Consider nursing home leaders, frontline leaders, persons directly involved in the intervention, and personnel with special expertise.
  2. Ask key stakeholders to review your action plan and to provide input. Specifically request that they identify any potential problem areas and offer solutions.
  3. Modify your action plan based on their input, if needed.

Tools and Resources:

  • N/A.

Tips for Success:

  • You may want to ask some stakeholders to review only certain sections of the action plan.

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Current as of October 2008
Internet Citation: Implementation Guide, 2: TeamSTEPPS® Long-Term Care Version. October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/implement/implguide1.html