SummaryIn setting out to improve safety through enhanced team communications, Abington Memorial Hospital implemented TeamSTEPPS™ (Strategies and Tools to Enhance Performance and Patient Safety)1 with other initiatives. As a result, the hospital has experienced significant improvements in patient outcomes and care processes since reinvigorating this effort in 2006. Quantifiable results include a 27-percent decline in inpatient adverse events as measured by the Global Trigger Tool and a 30-percent decrease in crude mortality rate, more proactive rescue of at-risk patients, better hand hygiene, improved staff perceptions of teamwork, and anecdotal reports of better communication processes.Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including adverse events, mortality, and hand hygiene compliance, as well as post-implementation surveys on staff perceptions of teamwork and communication.
Developing OrganizationsAbington Memorial Hospital; Agency for Healthcare Research and Quality; Department of Defense
Date First Implemented2006
Problem AddressedAccording to a seminal Institute of Medicine report published in 1999, between 44,000 and 98,000 patients die each year in the United States as a result of preventable medical errors in the inpatient setting.2 Unfortunately, patient safety remains at suboptimal levels, due in large part to ineffective communication and teamwork and the lack of a culture of safety in most institutions.
- Poor communication, suboptimal teamwork as a root cause of errors: In an analysis of more than 3,000 sentinel events between 1995 and 2004, the Joint Commission found that nearly two-thirds (approximately 65 percent) were caused by poor communication.3 Many other studies have found an association between suboptimal teamwork and higher rates of medical error.4
- Unrealized benefits of a "culture of safety": According to the Institute of Medicine, health care organizations need to develop a "culture of safety" so that personnel and processes focus on improving reliability and safety.2 However, despite good intentions and some improvements, many institutions still do not have a culture of safety. Although Abington Memorial Hospital had not experienced any significant safety events, leaders still recognized the need to enhance communication and teamwork as a way to improve patient outcomes.
Description of the Innovative ActivityAbington Memorial Hospital has pursued a number of activities to build a culture of safety, including TeamSTEPPS™ (Strategies and Tools to Enhance Performance and Patient Safety) training and other initiatives designed to enhance communication, teamwork, and awareness of safety issues. Key activities include the following:
- Dedicated patient safety department: The Center for Patient Safety and Healthcare Quality is a newly created hospital department that promotes and oversees patient safety initiatives and disseminates patient safety information. The hospital's chief medical officer assumed a second role as chief patient safety officer, and has oversight of this department.
- Mandatory TeamSTEPPS™ training: Physicians, residents, and nursing department staff participate in a mandatory TeamSTEPPS™ training course. Training content includes a discussion of the foundation and basics of teamwork, teamwork structure, leadership, situational awareness and monitoring, team communication, and mutual support. Participants learn about practical tools and strategies that they can use in the clinical setting. The hospital provides continuing education units for nurses and continuing medical education credits for physicians on completion of training. Information provided in April 2010 indicates that the hospital has trained more than 2,000 nurses and nearly 200 residents (representing more than 95 percent of the nursing and resident staff) and almost 700 attending physicians. More details on training logistics can be found in the Planning and Development section.
- TeamSTEPPS™ communication tools: Teams in units and departments use TeamSTEPPS™ tools on an ongoing basis to facilitate and enhance communication with team members about patient care. Examples include the following:
- Unit briefings and huddles: For fiscal year 2009, the hospital goal is to conduct briefings at the beginning of each shift. Unit staff meet and review a briefing checklist that addresses specified topics, such as staff planning, supplies and equipment needed, patients with special circumstances (e.g., language barriers, high risk of falling or developing a pressure ulcer, delirium), expected patient flow, bed availability, and patient transport needs. Huddles—ad hoc planning meetings to establish situational awareness and reinforce or adjust care plans—occur throughout the shift as needed. Information provided in April 2010 indicates that the number of units holding safety briefings increased to 80 percent in February 2010 up from 56 percent in February of 2009.
- Timeouts: Before each invasive procedure, the operating room nurse calls a timeout so that the nurse, physician, anesthesiologist, and other clinicians can verbalize and affirm agreement about critical facts (e.g., patient name, procedure, site, special safety issues, and blood and equipment needs). Information provided in April 2010 indicates that, building on communication skills learned from team training, the hospital incorporated the World Health Organization (WHO) Surgical Safety checklist into the timeout process in the operating room. This 19-item checklist was designed by health care professionals at WHO in response to safety issues in operating rooms around the world.
- SBAR (Situation, Background, Assessment, Recommendation): Clinicians use the SBAR technique during shift transitions, patient handoffs and transfers, and other circumstances in which physicians and nurses need to communicate critical, complete information about a patient.
- Cross-monitoring: Caregivers are encouraged to monitor each other's actions (e.g., proper hand hygiene), creating a "safety net" that allows for the quick identification of errors and oversights to prevent escalation to harm.
- Other TeamSTEPPS™ tools: Other tools applied by Abington caregivers include the two-challenge rule (which calls for the voicing of any concern at least twice); the "CUS" ("I am Concerned, I am Uncomfortable, this is a Safety issue") strategy for voicing concerns (which stresses the importance of saying "I am concerned," "I am uncomfortable," and/or "This is a safety issue"); and callouts in which crucial information (e.g., information about an incoming trauma patient) is articulated verbally so that all team members are aware of it.
- Other strategies and activities: A number of additional initiatives have been adopted to maintain a high level of awareness about patient safety at the hospital.
- Engagement of board of trustees: Spurred by the Getting Boards on Board intervention promoted by the Institute for Healthcare Improvement (IHI) Five Million Lives Campaign, the patient safety department sponsors monthly executive "walk-arounds." Led by an administrative leader, board members visit different hospital units to gain an important understanding of how care is delivered; the goal of these visits is to allow the board to make more informed decisions about administrative policies that affect patient safety. In addition, the first 30 minutes of monthly board meetings are dedicated to discussing patient safety issues, initiatives, and improvements.
- Patient safety coaches: A patient safety coach is assigned by each unit and department to attend a monthly meeting led by patient safety department representatives. Coaches are asked to commit to informing 10 members of the hospital staff about the topics covered that month and to promote safety behaviors. Coaches also disseminate patient safety information, including new hospital initiatives and assist in collecting unit-based data for improvement.
- Early use of Medical Emergency Team (MET): Clinicians can call the MET (composed of a third-year resident, critical care nurse, and, if needed, a respiratory therapist) when they suspect that a patient is at risk of respiratory or cardiac arrest; the MET delivers appropriate care and/or transfers the patient to the intensive care unit, thereby rescuing patients before they experience a cardiopulmonary arrest.
- External training: The patient safety department identifies and promotes various external patient safety training opportunities for hospital staff, including training at the Harvard University–based Patient Safety Officer Training School and the IHI's annual convention.
- Engage Every Employee (E-3) card: Employees write three specific commitments they can make to improve patient safety or patient satisfaction on a special card, review the card with their supervisor, and wear the card behind their staff identification badges.
- Ongoing solicitation of suggestions and concerns: Patient safety suggestion boxes are located in prominent locations. In addition, patients, families, and staff can dial S-A-F-E on an internal hospital telephone or click on a link provided on the hospital's intranet to report a safety concern or suggestion. The S-A-F-E telephone line and computer link are monitored on a regular basis.
- Information sharing: The patient safety department publishes its own newsletter, and department staff members write monthly articles on safety for inclusion in the nurse and medical staff newsletters. The patient safety department also promotes learning through publication of Patient Safety Briefings—one-page flyers sent via e-mail to department directors, unit supervisors, and patient safety coaches. In addition, hospital-level and unit-level report cards are distributed to all units that measure performance versus the Joint Commission's National Patient Safety Goals.
- Simulation center: Staff members have the opportunity to practice both teamwork skills and clinical decisionmaking to advance reliable outcomes.
Context of the InnovationAbington Memorial Hospital is a 600-bed, nonprofit regional teaching hospital in Abington, PA (a suburb of Philadelphia), that handles nearly 40,000 inpatient admissions and more than 96,000 emergency patients (at its level II trauma center) each year. The hospital has 5,500 employees, 900 physicians, and 1,200 volunteers. The hospital pursued TeamSTEPPS™ training and the development of a culture of safety as a way to achieve patient safety goals defined by hospital leadership.
ResultsAbington has experienced significant improvements in patient outcomes and care processes since first beginning to develop a culture of patient safety in 2003 (although the hospital cannot prove a direct link between these improvements and TeamSTEPPS™ and the other initiatives1). Quantifiable results include fewer adverse events as measured by the Global Trigger Tool, a lower mortality rate, more proactive rescue of at-risk patients, better hand hygiene, improved staff perceptions of teamwork, and anecdotal reports of better communication processes.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including adverse events, mortality, and hand hygiene compliance, as well as post-implementation surveys on staff perceptions of teamwork and communication.
- Fewer adverse events and deaths: From fiscal year 2007 to fiscal year 2008, the hospital has experienced a 27-percent decline in inpatient adverse events per 1,000 patient days as measured by the Global Trigger Tool, a 19-percent decrease in total (inpatient and outpatient) adverse events per 1,000 patient days as measured by the Global Trigger Tool, and a 30-percent decline in crude hospital mortality rate.
- Proactive rescue of at-risk patients: Information provided in April 2010 indicates that codes outside of critical care in 2010 are 1.17 per 1,000 discharges, a decrease from the 2.78 per 1,000 discharges in 2005. This decrease suggests that unit staff members are now better at recognizing and communicating early warning signs of respiratory and cardiac arrest.
- Better hand hygiene: Information provided in April 2010 indicates that observational assessments conducted throughout the hospital show that hand hygiene compliance rates increased to 80 percent in 2010 from 41 percent in 2007.
- Improved staff perceptions of teamwork and communication: Nurse surveys conducted before and after implementation of TeamSTEPPS™ education found that the average score on questions related to teamwork, communication, leadership, responsibility for patient safety, support, and trust rose from roughly 3 to 4 (on a 5-point Likert scale) across all units.
- Better communication processes: Anecdotal reports suggest that team members are using TeamSTEPPS™ language/tools and other communication strategies on a regular basis and have incorporated expectations about colleagues' communication and teamwork into their daily work.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Development of oversight body: The hospital created the Center for Patient Safety and Healthcare Quality, a dedicated department that serves as an oversight body for all patient safety efforts.
- Preparation for TeamSTEPPS™ training: Two members of the department (who would later serve as the principal TeamSTEPPS™ educators) designed a training schedule to allow all Abington clinicians to eventually participate. These individuals customized existing TeamSTEPPS™ training materials and presentations to the hospital by incorporating pictures of Abington staff and hospital-specific data and stories. Nurses were surveyed about their perceptions of unit teamwork before training began.
- Implementation of TeamSTEPPS™: Initially, 4-hour training sessions were held twice weekly with approximately 30 participants in each session; early sessions catered to nurses and later expanded to include residents and attending physicians. Nurse managers were assigned to the first training session so that they could reinforce teamwork principles, which were subsequently taught to the staff. Over time, the Center for Patient Safety and Healthcare Quality staff trained additional instructors. Training sessions were also reconfigured into two 1.5-hour sessions to better accommodate medical staff schedules. A post-training teamwork survey was administered to nurses to help gauge the impact of the effort.
- Addition of new activities: Patient safety department staff continued to research and implement additional activities designed to improve communication and awareness of patient safety, even as TeamSTEPPS™ was being prepared and implemented.
Resources Used and Skills Needed
- Staffing: The dedicated patient safety department includes 12 full-time staff, including a chief patient safety officer, a nursing director, an associate medical director of patient safety, nurses, and allied health professionals who serve as patient safety specialists, and information technology staff. All staff members participate in the training as a part of their regular duties; no overtime is incurred.
- Costs: Data regarding the total costs of the patient safety initiatives are unavailable. Costs include the salaries and benefits of the patient safety department staff, incidental costs related to TeamSTEPPS™ training (materials and refreshments), staff and clinician time spent in training sessions, and the costs of attending external training sessions. TeamSTEPPS™ materials are available at no cost.
Funding SourcesAbington Memorial Hospital
Tools and Other ResourcesTeamSTEPPS™, developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality, is a comprehensive program to identify communication and cultural problems and improve care processes. TeamSTEPPS™ combines standardized communication techniques, tools, and teamwork training to enhance the quality of patient care, decrease medical errors, and improve staff morale. More information about TeamSTEPPS™, including TeamSTEPPS™ tools, is available at http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.
The WHO Surgical Safety Checklist is available at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html
The Institute for Healthcare Improvement's Global Trigger Tool, which uses cues, or "triggers," for measuring adverse events, is available at http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IHIGlobalTriggerToolforMeasuringAEs.htm.
Getting Started with This Innovation
- Ensure alignment of hospital goals: Patient safety improvements will be easier to achieve if patient safety–specific goals are aligned with the hospital's overall goals.
- Acknowledge the financial burden of training: Be up front with senior leadership about the cost of temporarily removing staff from the work environment to undergo training.
- Assess baseline perceptions: Use surveys to determine staff perceptions about teamwork and communication.
- Choose instructors carefully: Excellent clinicians may not make excellent TeamSTEPPS™ instructors. Instructors should be engaging and dynamic and have excellent communication skills and a genuine passion for patient safety.
Sustaining This Innovation
- Elicit suggestions from all levels of the organization: Patient safety improvements can come from the top or bottom of an organization. In addition to disseminating information and policies from senior leadership, encourage employees across all levels of the organization to make safety suggestions, highlight issues of concern, and model behaviors.
- Make patient safety personal: Ask employees to consider their own responsibility with regard to patient safety, and determine how they can change their behaviors to improve safety.
- Inject humor and stories into training: Although patient safety is a serious subject, injecting some lightheartedness into the training will improve participant engagement. In addition, incorporating real stories and practical scenarios that simulate the work environment makes the training more important and relevant to participants, thus increasing the likelihood that it will prompt behavior change.
- Monitor and share results: Maintaining focus on patient safety can be difficult, especially when there are a myriad of other initiatives vying for staff attention. To help keep this focus, monitor and share data on the impact of the program in meetings and publications, highlighting tangible improvements in patient care. In addition, continue to incorporate patient safety into hospital goals, which should help to sustain the focus on patient safety.
Contact the InnovatorLinda Mimm, RN-BC, MJ, DL, CPHQ
Patient Safety and Quality Specialist
Abington Memorial Hospital
1200 Old York Road
Abington, PA 19001
Phone: (215) 481-7178
Innovator DisclosuresDr. Mimm has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesMore information about Abington Memorial Hospital's culture of safety is available at http://www.amh.org/aboutus/patientsafetyandquality/.
2 The Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000.
3 The Joint Commission. Improving handoff communications: meeting National Patient Safety Goal 2E. Jt Comm Perspect Patient Saf. 2006 Aug;6(8):9-15.
Catchpole K, Mishra K, Handa A, et al. Teamwork and error in the operating room. Ann Surg. 2008 Apr;247(4):699-706. [PubMed]
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Original publication: March 30, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 28, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 12, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.