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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

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Using Simulation in TeamSTEPPS® Training

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.

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Objectives

• 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

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Course Outline

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

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Simulation

• 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

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Keys to Success

• 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

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TeamSTEPPS Resources

• 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

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EBAT

• 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)

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Phase 1

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

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Specify Teamwork Skills

• 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.

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Define Learning Objectives

• 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

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Example Objective

Communication

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

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Choose a Clinical Context

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.

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TeamSTEPPS 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.

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Clinical Context

• 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.

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Define Event Sets

• 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

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Define Targeted Responses

• 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.

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Guidance

• 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.

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Trauma Example Pre-Hospital/Transport

Trauma Phase Event Set	Triggers	Expected 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 team	Leadership 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

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Trauma Example Primary Survey

Trauma Phase Event Set	Trigger	Expected Team Behaviors
Primary Survey
	Too many people in room	Leadership 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 missing	Situation Monitoring Team member identifies equipment issue Team member remedies issue (e.g., replaces, fixes, or obtains needed equipment) quickly

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Scenario Development

• 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

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Phase 2

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

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Team Performance Observation Tool

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

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Consider Level of Analysis

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

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Clarify the Purpose

• 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

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Decide What to Measure

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

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Outcomes

• 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).

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Process

• 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.

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Measurement Tips

• 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.

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Select a Measure

• 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.

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Checklist Tips

• 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.

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Checklist

Action/Behavior	Yes	No
Assess Airway
Breathing
Circulation/FAST Exam
Disability
Exposure and Environment

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Frequency Count Tips

• 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.

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Frequency Count

Communication	Positive Instances
Check-back	8
Call-outs
SBAR	2
Unintelligible Communications
Mutual Support	Positive Instances
Two-Challenge
CUS	4
Task Assistance

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Graphic Rating Scale

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

   Scale legend: 1 = ineffective through 6 = very effective

   Ineffective					Very Effective
   1	2	3 (checked)	4	5	6

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

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

   Strongly Disagree					Strongly Agree
   1	2	3	4	5 (checked)	6

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Anchored Rating Scale

Communication: Used check-back during trauma resuscitation.

Did not use check- back

Used check-back once to confirm care plan at end of case

Used check-back to confirm all medication orders

Used check-back to confirm critical orders, primary and secondary survey

Used check-back to confirm all critical orders (checked)

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Rating Scales

• 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.

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Measures

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.

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Phase 3

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

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Description Phase

• 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.

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Analysis Phase

• 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?

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Application/Generalization Phase

• 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.

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Tip for Success 1

• 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.

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Tip for Success 2

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

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Tip for Success 3

• 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.

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Rater Scoring Guide

Team Behaviors	Hit	Variation in Quality	Miss
Communication
SBAR – uses structured communication (situation, background, assessment, recommendation)	all components (situation, background, assessment, and recommendation) are present	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)	structured communication was NOT used at all when appropriate (e.g., during a handoff)
Call-out – verbalizes critical information to the entire team	a team member clearly verbalizes critical information to all team members	critical information was only verbalized to one of the team members and not all of them	critical information was not verbalized
Check-back – uses closed-loop communication	a sender initiated a message, the receiver accepted the message and provided feedback confirmation, and the sender verified message was received	a 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

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Tip for Success 4

• 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.

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Tip for Success 5

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

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Teamwork Actions

• 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.

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