Using Simulation in TeamSTEPPS Training: Classroom Slides Training GuideTeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety. Using Simulation in TeamSTEPPS® TrainingClassroom SlidesUsing Simulation in TeamSTEPPS® TrainingObjectivesCourse OutlineSimulationKeys to SuccessTeamSTEPPS ResourcesEBATPhase 1Specify Teamwork SkillsDefine Learning ObjectivesExample ObjectiveChoose a Clinical ContextTeamSTEPPS Scenario 86Clinical ContextDefine Events SetsDefine Targeted ResponsesGuidanceTrauma Example Pre-Hospital/TransportTrauma Example Primary SurveyScenario DevelopmentPhase 2Team Performance Observation ToolConsider Level of AnalysisClarify the PurposeDecide What to MeasureOutcomesProcessMeasurement TipsSelect a MeasureChecklist TipsChecklistFrequency Count TipsFrequency CountGraphic Rating ScaleAnchored Rating ScaleRating ScalesMeasuresPhase 3Description PhaseAnalysis PhaseApplication/Generalization PhaseTip for Success 1Tip for Success 2Tip for Success 3Rater Scoring GuideTip for Success 4Tip for Success 5Teamwork Actions Using Simulation in TeamSTEPPS® TrainingDecorative image: Logos for the Department of Health and Human Services (DHHS), Agency for Healthcare Research and Quality (AHRQ), Department of Defense (DoD), and Tricare.Return to Top ObjectivesTo know and be able to apply the Event Based Approach to TrainingTo know and be able to develop TeamSTEPPS training scenariosTo know and be able to develop TeamSTEPPS performance measuresTo know and be able to conduct effective debriefs of team performanceReturn to Top Course OutlinePhase 1. Scenario Development ExercisePhase 2. Measurement Development ExercisePhase 3. DebriefingLessons LearnedReturn to Top SimulationTeam skills are developed through practice and feedbackSimulation allows health care professionals to practice TeamSTEPPS skills and strategies in a safe learning environmentSimulation includes Role playPart-task trainersHuman patient simulationStandardized patientsReturn to Top Keys to SuccessProper scenario design Focus on learning objectivesProvide more than one opportunity to practice team behaviorsAccurate measurement Include process and outcome measuresCapture behaviorsDebriefing Learning happens in the debriefInclude feedback on how to improve performanceReturn to Top TeamSTEPPS ResourcesScenarios � Tab I 131 VignettesOrganized by department and TeamSTEPPS skill and toolTeam Performance Observation Tool � Tab A, Appendix C Tool for observing team performanceObservers should practice using the toolCan be adopted to a particular type of careReturn to Top EBATEvent-Based Approach to Training (EBAT) Not a new method U.S. Navy, Targeted Acceptable Responses to Generated Events (TARGETs) (Fowlkes, Lane, Salas, Franz, & Oser, 1994)FAA Advisory Circular 120-35C Line Operational SimulationsHow to design simulation scenariosHealth care domain Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) (Rosen, Salas, Silvestri, Wu, & Lazzara, 2008)Return to Top Phase 1Scenario Development Specify teamwork skillsDefine learning objectivesChoose clinical contextDefine event setsDefine targeted responsesReturn to Top Specify Teamwork SkillsSkills are general categories of behavior you want to trainTeamwork is too complex to train in a single scenario Need to focus on a subset of competenciesThere are four core skills in TeamSTEPPSDecorative Image: TeamSTEPPS Logo. The logo is a triangle that has 4 blocks inside a circle entitled Patient Care Team. �The words Knowledge, Attitudes, and Performance appear in each point of the triangle and point through the Patient Care Team circle to the Skills blocks entitled Leadership, Communication, Situation Monitoring, and Mutual Support.Return to Top Define Learning ObjectivesLearning objectives should be explicit and measurable Focus on specific TeamSTEPPS behaviorsInclude the following information Performance � Specifies the behaviorCondition(s) � Specifies the conditions under which the behavior occursStandards � Specifies the level of expected performanceReturn to Top Example ObjectiveCommunicationLearning Objective: Uses two-challenge rule or CUS to advocate for a patient in labor experiencing frequent, strong contractionsReturn to Top Choose a Clinical ContextConsiderationsMedicine is a notoriously task-specific domain.Not all contexts are equal for training purposes.Choose a clinical context that affords opportunities to perform.TeamSTEPPS provides 131 scenarios (Tab I).Contexts should be appropriate for eliciting the team behavior of interest.Return to Top TeamSTEPPS Scenario 86Sally 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.Return to Top Clinical ContextScenario 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.Return to Top Define Event SetsEvent sets are the building blocks of a scenarioEvent sets consist of: Trigger � The incident to elicit the team behaviorDistracters � Characteristics of the situation (i.e., conditions) in which the behavior is to occurExamples Trigger: The OB attending states he wants the patient to be dilated 4�5 cm before she receives the epiduralDistracter: Sally has a strong contraction and screamsReturn to Top Define Targeted ResponsesTargeted responses Behavioral responses to each event set trigger.Expected levels of performance (i.e., standards).Example Trigger: The OB attending states he wants the patient to be dilated 4�5 cm before she receives the epidural.Response: The nurse uses two-challenge rule or CUS to advocate to the physician that Sally should receive pain medication now.Return to Top GuidanceSimulation scenarios should consist of 3-5 event sets. Provides more than one opportunity to demonstrate behaviors.Creates reliability.Each event set should not include more than one trigger event.Event sets can be created by breaking a clinical procedure into chunks. Embed triggers into these chunks.Return to Top Trauma Example Pre-Hospital/TransportTrauma Phase Event SetTriggersExpected Team BehaviorsPre-Hospital/ TransportPatient arrives without advance notice ("zero time")Leadership Team leader assembles team quicklyTeam leader advocates a planInaccurate or incomplete information from EMS/rescue teamLeadership Team leader advocates a plan based on known informationCommunication Team members use call-outs and check-backs to share accurate patient injury information and discoveries through surveysTeam members request information from EMS/rescue when information has not been providedReturn to Top Trauma Example Primary SurveyTrauma Phase Event SetTriggerExpected Team BehaviorsPrimary SurveyToo many people in roomLeadership Team leader may ask non-team members to leaveCommunication Team members communicate findings and orders with clear call-outs and check-backsTeam members are not distracted by othersEquipment not working or is missingSituation Monitoring Team member identifies equipment issueTeam member remedies issue (e.g., replaces, fixes, or obtains needed equipment) quicklyReturn to Top Scenario DevelopmentSelect a scenario from Tab IIdentify/develop the following items TeamSTEPPS skillLearning objective(s)Clinical contextEvent set Trigger and distractersTargeted responsesBe prepared to present your resultsDecorative image: ExerciseReturn to Top Phase 2Develop Measures Consider level of analysisClarify purposeDecide what to measureSelect a measureReturn to Top Team Performance Observation ToolLeadershipUtilizes resources efficiently to maximize team performanceBalances workload within the teamDelegates tasks or assignments, as appropriateConducts briefs, huddles, and debriefsEmpowers team members to speak freely and ask questionsSituation MonitoringIncludes patient/family in communicationCross monitors fellow team membersApplies the STEP process when monitoring the situationFosters communication to ensure team members have a shared mental model Mutual Support RatingProvides task-related supportProvides timely and constructive feedback to team membersEffectively advocates for the patientUses the Two-Challenge rule, CUS, and DESC script to resolve conflictCollaborates with team membersCommunication RatingProvides brief, clear, specific, and timely information to team membersSeeks information from all available sourcesVerifies information that is communicatedUses SBAR, call-outs, check-backs and handoff techniquesReturn to Top Consider Level of AnalysisIndividuals MDNurseAnesthesiaTeams Delivery teamC-Section teamMulti-team — Team Structure Core teamContingency teamAdministrative teamReturn to Top Clarify the PurposeDiagnose root causes of performance deficiencies Identify specific weaknessesProvide feedback Relay information regarding strengths and weaknesses as a remediation planAssessment Evaluate the level of proficiency or readinessReturn to Top Decide What to MeasureOutcomes tend to be more quantifiable and answer the question "What happened?"Processes answer the question "Why did it happen?"Return to Top OutcomesOutcomes Sometimes referred to as measures of effectiveness (MOEs).Provide an indication of the extent to which the outcome of the task was successful.Are important for most measurement purposes.What outcomes could we assess? Accuracy — Precision of performance (e.g., correct medication).Timeliness — How long (e.g., time to incision).Productivity — How much (e.g., patient volume in ED).Efficiency — Ratio of resources required versus used (e.g., OR supplies).Return to Top ProcessProcesses Sometimes referred to as measures of performance (MOPs).Explain how and why certain outcomes may have happened ("Was the decision made right?" versus "Was the right decision made?").Important when diagnosing root causes of performance deficiencies and providing feedback or follow-on training.Types of Process Procedural — Taskwork.Non-procedural — Taskwork.Teamwork.Return to Top Measurement TipsAssess processes as well as outcomes when diagnosing performance deficiencies or providing feedback.Consider measuring at multiple levels to identify the weak link.Provide multiple opportunities to perform the same task or skill over the course of an exercise.Return to Top Select a MeasureChecklists Consist of items/actions that have dichotomous answers such as Yes/No; Right/Wrong; Performed/Not Performed.Example: Primary Survey ABCs.Frequency counts Indication of the number of times that a behavior, action, or error occurs.Example: Use of CUS, SBAR, Two-Challenge.Rating scales Numerical or descriptive judgment of how well a task was performed.Return to Top Checklist TipsBest used with a scripted scenario versus "free play".Items should be related to triggers embedded into the scenario.Each item should represent a single action taken by the individual, team, or battlegroup.Label or define the response category that you are using.Return to Top ChecklistAction/BehaviorYesNoAssess Airway Breathing Circulation/FAST Exam Disability Exposure and Environment Return to Top Frequency Count TipsFrequency counts are better when measuring acts of commission than acts of omission. Overt actions or errors versus failing to demonstrate a particular behavior.Frequency counts are good when you want to know how often a specific action is taken or task is performed.Frequency counts can be recorded during a critical event in an exercise or throughout the entire scenario.Return to Top Frequency CountCommunicationPositive InstancesCheck-back8Call-outs SBAR2Unintelligible Communications Mutual SupportPositive InstancesTwo-Challenge CUS4Task Assistance Return to Top Graphic Rating ScaleThe team leader assigned roles to the Trauma Team. Scale legend: 1 = ineffective through 6 = very effectiveIneffective Very Effective123 (checked)456The PGY2 used check-back to confirm orders. Scale legend: 1 = strongly disagree through 6 = strongly agreeStrongly Disagree Strongly Agree12345 (checked)6Return to Top Anchored Rating ScaleCommunication: Used check-back during trauma resuscitation.Did not use check- backUsed check-back once to confirm care plan at end of caseUsed check-back to confirm all medication ordersUsed check-back to confirm critical orders, primary and secondary surveyUsed check-back to confirm all critical orders (checked)Return to Top Rating ScalesUses 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.Tips Define or clearly describe what you are measuring.Include a specific stem or item to accompany the rating scale.Return to Top MeasuresDevelop a measure to assess performance for the scenario you developed earlierBe prepared to present your measuresDecorative image: Penguin on a bicycle with the word 'Exercise' under the image.Return to Top Phase 3Debriefing Introduce the debrief process.Describe what happened.Conduct an analysis of performance.Identify lessons learned.Return to Top Description PhaseRecap of what happened in the scenario Team members share their perspectives on what occurred during the scenario and reach common ground.This helps ensure everyone takes away similar lessons from the experience.How measurement can help Provides a structure for understanding the scenario. The event sets or behavior categories can be used to structure discussion.Focus on critical aspects of performance. Helps to keep the discussion focused on events relevant to the learning objectives.Return to Top Analysis PhaseA systematic investigation of why things happened in the scenario as they did The team focuses on understanding what went well and what could have been done better.How measurement can help Can help compare the team�s performance with standards of performance Were the TeamSTEPPS behaviors performed when necessary? If so, were they performed correctly or could they be improved?Return to Top Application/Generalization PhaseA look ahead to how the team can generalize what they learned in the scenario to their daily practice The team generates lessons learned and discuss what needs to be corrected and how to correct it.How measurement can help Explicit event sets can be used to draw parallels between the scenario and the actual clinical environment.Explicit measures associated with these events help promote reflection about how to transfer what went well to the actual clinical environment.Return to Top Tip for Success 1Tip 1: Don�t overwhelm learners or observers — Keep it simple People can integrate only a few key learning points from a scenario.Observers have a limited attention span and frequently have to multi-task. Don�t ask too much; you won�t like what you get.Rule of thumb: Have a key event every 1 to 2 minutes of scenario time.Return to Top Tip for Success 2Tip 2: Telling someone how well they did is not good enough.They need diagnostic feedback SpecificBehaviorally focusedDescriptiveReturn to Top Tip for Success 3Tip 3: Train observers Training, by definition, is systematic. For measurement to guide this process, it too must be systematic, reliable, and valid.Make sure everyone has common expectations about performance.Develop and use a scoring guide.Return to Top Rater Scoring GuideTeam BehaviorsHitVariation in QualityMissCommunicationSBAR � uses structured communication (situation, background, assessment, recommendation)all components (situation, background, assessment, and recommendation) are presentseveral, 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)structured communication was NOT used at all when appropriate (e.g., during a handoff)Call-out � verbalizes critical information to the entire teama team member clearly verbalizes critical information to all team memberscritical information was only verbalized to one of the team members and not all of themcritical information was not verbalizedCheck-back � uses closed-loop communicationa sender initiated a message, the receiver accepted the message and provided feedback confirmation, and the sender verified message was receiveda team member initiates communication and the other team member provides verification of receipt and understanding, but the initiator DOES NOT verify this understanding is correct.a sender initiated a message but the receiver DID NOT provide feedback confirmation, and the sender did not verify message was receivedReturn to Top Tip for Success 4Tip 4: Keep teamwork and clinical skills separateUse "dual debriefs" Provide feedback on teamwork skills as a team.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. 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.Return to Top Tip for Success 5Tip 5: Event-based methods involve more than just measurement Good training design practicesGood scenario design practicesGood debrief facilitation practicesReturn to Top Teamwork ActionsApply the Event Based Approach to Training.Able to develop TeamSTEPPS training scenarios.Able to develop TeamSTEPPS performance measures.Know how to conduct effective debriefs of team performance.Return to Top Current as of November 2008 Internet Citation: Using Simulation in TeamSTEPPS Training: Classroom Slides: Training Guide. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/simulation/simulationslides/simslides.html
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