Using Simulation in TeamSTEPPS Training: Classroom Slides

Training Guide

TeamSTEPPS 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® Training

Classroom Slides

  1. Using Simulation in TeamSTEPPS® Training
  2. Objectives
  3. Course Outline
  4. Simulation
  5. Keys to Success
  6. TeamSTEPPS Resources
  7. EBAT
  8. Phase 1
  9. Specify Teamwork Skills
  10. Define Learning Objectives
  11. Example Objective
  12. Choose a Clinical Context
  13. TeamSTEPPS Scenario 86
  14. Clinical Context
  15. Define Events Sets
  16. Define Targeted Responses
  17. Guidance
  18. Trauma Example Pre-Hospital/Transport
  19. Trauma Example Primary Survey
  20. Scenario Development
  21. Phase 2
  22. Team Performance Observation Tool
  23. Consider Level of Analysis
  24. Clarify the Purpose
  25. Decide What to Measure
  26. Outcomes
  27. Process
  28. Measurement Tips
  29. Select a Measure
  30. Checklist Tips
  31. Checklist
  32. Frequency Count Tips
  33. Frequency Count
  34. Graphic Rating Scale
  35. Anchored Rating Scale
  36. Rating Scales
  37. Measures
  38. Phase 3
  39. Description Phase
  40. Analysis Phase
  41. Application/Generalization Phase
  42. Tip for Success 1
  43. Tip for Success 2
  44. Tip for Success 3
  45. Rater Scoring Guide
  46. Tip for Success 4
  47. Tip for Success 5
  48. Teamwork Actions

 

Using Simulation in TeamSTEPPS® Training

Text description is below the image.

Decorative 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


 

Objectives

Text description is below the image.

  • To know and be able to apply the Event Based Approach to Training
  • To know and be able to develop TeamSTEPPS training scenarios
  • To know and be able to develop TeamSTEPPS performance measures
  • To know and be able to conduct effective debriefs of team performance

Return to Top


 

Course Outline

Text description is below the image.

  • Phase 1. Scenario Development
    • Exercise
  • Phase 2. Measurement Development
    • Exercise
  • Phase 3. Debriefing
  • Lessons Learned

Return to Top


 

Simulation

Text description is below the image.

  • Team skills are developed through practice and feedback
  • Simulation allows health care professionals to practice TeamSTEPPS skills and strategies in a safe learning environment
  • Simulation includes
    • Role play
    • Part-task trainers
    • Human patient simulation
    • Standardized patients

Return to Top


 

Keys to Success

Text description is below the image.

  • Proper scenario design
    • Focus on learning objectives
    • Provide more than one opportunity to practice team behaviors
  • Accurate measurement
    • Include process and outcome measures
    • Capture behaviors
  • Debriefing
    • Learning happens in the debrief
    • Include feedback on how to improve performance

Return to Top


 

TeamSTEPPS Resources

Text description is below the image.

  • Scenarios – Tab I
    • 131 Vignettes
    • Organized by department and TeamSTEPPS skill and tool
  • Team Performance Observation Tool – Tab A, Appendix C
    • Tool for observing team performance
    • Observers should practice using the tool
    • Can be adopted to a particular type of care

Return to Top


 

EBAT

Text description is below the image.

  • Event-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 Simulations
        • How to design simulation scenarios
    • Health care domain
      • Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) (Rosen, Salas, Silvestri, Wu, & Lazzara, 2008)

Return to Top


 

Phase 1

Text description is below the image.

  • Scenario Development
    1. Specify teamwork skills
    2. Define learning objectives
    3. Choose clinical context
    4. Define event sets
    5. Define targeted responses

Return to Top


 

Specify Teamwork Skills

Text description is below the image.

  • Skills are general categories of behavior you want to train
  • Teamwork is too complex to train in a single scenario
    • Need to focus on a subset of competencies
    • There are four core skills in TeamSTEPPS

Decorative 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 Objectives

Text description is below the image.

  • Learning objectives should be explicit and measurable
    • Focus on specific TeamSTEPPS behaviors
    • Include the following information
      • Performance – Specifies the behavior
      • Condition(s) – Specifies the conditions under which the behavior occurs
      • Standards – Specifies the level of expected performance

Return to Top


 

Example Objective

Text description is below the image.

Communication

Learning Objective: Uses two-challenge rule or CUS to advocate for a patient in labor experiencing frequent, strong contractions

Return to Top


 

Choose a Clinical Context

Text description is below the image.

Considerations

  • Medicine 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 86

Text description is below the image.

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.

Return to Top


 

Clinical Context

Text description is below the image.

  • 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.

Return to Top


 

Define Event Sets

Text description is below the image.

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

Return to Top


 

Define Targeted Responses

Text description is below the image.

  • Targeted 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


 

Guidance

Text description is below the image.

  • Simulation 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/Transport

Text description is below the image.

Trauma Phase Event SetTriggersExpected Team Behaviors
Pre-Hospital/
Transport
Patient arrives without advance notice ("zero time")Leadership
  • Team leader assembles team quickly
  • Team leader advocates a plan
Inaccurate or incomplete information from EMS/rescue teamLeadership
  • Team leader advocates a plan based on known information
Communication
  • Team members use call-outs and check-backs to share accurate patient injury information and discoveries through surveys
  • Team members request information from EMS/rescue when information has not been provided

Return to Top


 

Trauma Example Primary Survey

Text description is below the image.

Trauma Phase Event SetTriggerExpected Team Behaviors
Primary Survey
Too many people in roomLeadership
  • Team leader may ask non-team members to leave
Communication
  • Team members communicate findings and orders with clear call-outs and check-backs
  • Team members are not distracted by others
Equipment not working or is missingSituation Monitoring
  • Team member identifies equipment issue
  • Team member remedies issue (e.g., replaces, fixes, or obtains needed equipment) quickly

Return to Top


 

Scenario Development

Text description is below the image.

  • Select a scenario from Tab I
  • Identify/develop the following items
    • TeamSTEPPS skill
    • Learning objective(s)
    • Clinical context
    • Event set
      • Trigger and distracters
    • Targeted responses
  • Be prepared to present your results

Decorative image: Exercise

Return to Top


 

Phase 2

Text description is below the image.

  • Develop Measures
    1. Consider level of analysis
    2. Clarify purpose
    3. Decide what to measure
    4. Select a measure

Return to Top


 

Team Performance Observation Tool

Text description is below the image.

Leadership

  • Utilizes resources efficiently to maximize team performance
  • Balances workload within the team
  • Delegates tasks or assignments, as appropriate
  • Conducts briefs, huddles, and debriefs
  • Empowers team members to speak freely and ask questions

Situation Monitoring

  • Includes patient/family in communication
  • Cross monitors fellow team members
  • Applies the STEP process when monitoring the situation
  • Fosters communication to ensure team members have a shared mental model

Mutual Support Rating

  • Provides task-related support
  • Provides timely and constructive feedback to team members
  • Effectively advocates for the patient
  • Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict
  • Collaborates with team members

Communication Rating

  • Provides brief, clear, specific, and timely information to team members
  • Seeks information from all available sources
  • Verifies information that is communicated
  • Uses SBAR, call-outs, check-backs and handoff techniques

Return to Top


 

Consider Level of Analysis

Text description is below the image.

  • Individuals
    • MD
    • Nurse
    • Anesthesia
  • Teams
    • Delivery team
    • C-Section team
  • Multi-team — Team Structure
    • Core team
    • Contingency team
    • Administrative team

Return to Top


 

Clarify the Purpose

Text description is below the image.

  • Diagnose root causes of performance deficiencies
    • Identify specific weaknesses
  • Provide feedback
    • Relay information regarding strengths and weaknesses as a remediation plan
  • Assessment
    • Evaluate the level of proficiency or readiness

Return to Top


 

Decide What to Measure

Text description is below the image.

  • Outcomes tend to be more quantifiable and answer the question "What happened?"
  • Processes answer the question "Why did it happen?"

Return to Top


 

Outcomes

Text description is below the image.

  • Outcomes
    • 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


 

Process

Text description is below the image.

  • Processes
    • 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 Tips

Text description is below the image.

  • Assess 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 Measure

Text description is below the image.

  • Checklists
    • 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 Tips

Text description is below the image.

  • Best 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


 

Checklist

Text description is below the image.

Action/BehaviorYesNo
Assess Airway  
Breathing  
Circulation/FAST Exam  
Disability  
Exposure and Environment  

Return to Top


 

Frequency Count Tips

Text description is below the image.

  • Frequency 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 Count

Text description is below the image.

CommunicationPositive Instances
Check-back8
Call-outs 
SBAR2
Unintelligible Communications 
Mutual SupportPositive Instances
Two-Challenge 
CUS4
Task Assistance 

Return to Top


 

Graphic Rating Scale

Text description is below the image.

  1. The team leader assigned roles to the Trauma Team.

    Scale legend: 1 = ineffective through 6 = very effective

    Ineffective    Very Effective
    123 (checked)456

  2. The PGY2 used check-back to confirm orders.

    Scale legend: 1 = strongly disagree through 6 = strongly agree

    Strongly Disagree    Strongly Agree
    12345 (checked)6

Return to Top


 

Anchored Rating Scale

Text description is below the image.

Communication: 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 Scales

Text description is below the image.

  • Uses
    • 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


 

Measures

Text description is below the image.

Develop a measure to assess performance for the scenario you developed earlier

Be prepared to present your measures

Decorative image: Penguin on a bicycle with the word 'Exercise' under the image.

Return to Top


 

Phase 3

Text description is below the image.

  • Debriefing
    1. Introduce the debrief process.
    2. Describe what happened.
    3. Conduct an analysis of performance.
    4. Identify lessons learned.

Return to Top


 

Description Phase

Text description is below the image.

  • Recap 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 Phase

Text description is below the image.

  • A 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 Phase

Text description is below the image.

  • A 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 1

Text description is below the image.

  • Tip 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 2

Text description is below the image.

  • Tip 2: Telling someone how well they did is not good enough.
  • They need diagnostic feedback
    • Specific
    • Behaviorally focused
    • Descriptive

Return to Top


 

Tip for Success 3

Text description is below the image.

  • Tip 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 Guide

Text description is below the image.

Team BehaviorsHitVariation in QualityMiss
Communication
SBAR – 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 verbalized
Check-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 received

Return to Top


 

Tip for Success 4

Text description is below the image.

  • Tip 4: Keep teamwork and clinical skills separate
  • Use "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 5

Text description is below the image.

  • Tip 5: Event-based methods involve more than just measurement
    • Good training design practices
    • Good scenario design practices
    • Good debrief facilitation practices

Return to Top


 

Teamwork Actions

Text description is below the image.

  • Apply 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