TeamSTEPPS® in LTC: Communication Strategies to Promote Quality and Safety

Welcome and Overview

This session features communication strategies to promote quality and safety. It is designed to help train nursing home staff in teamwork and communication using specific evidence-based tools and strategies which are a part of TeamSTEPPS® 2.0. The session will provide an overview of the TeamSTEPPS® framework and competencies and explore specific TeamSTEPPS® tools and strategies as a way to improve teamwork and enhance resident safety. This session incorporates specific strategies and principles tailored to the long-term care (LTC) environment.

This session is one of a series of six sessions for nursing homes to support implementation of principles and practices of antibiotic stewarship and prevention and management of C. difficile infections.

Objectives

Describe the TeamSTEPPS® model, including the communication strategies.
Examine the value of adopting TeamSTEPPS® as a way to improve teamwork to enhance resident safety.
Use specific TeamSTEPPS® communication strategies to improve quality and safety in daily work.

How can you use this session?

This session was developed for nursing home leaders that want to optimize team performance by enhancing competency in teamwork and communication. Nursing home leaders can review the content in this session and decide which components would be helpful to include in educating other staff. The components can be shared and discussed during staff education sessions, or they can be accessed by staff online at any time. This session focuses on selected strategies and tools to enhance teamwork, communication, and resident safety.

Depending on which components you choose to review and/or share and discuss with staff, this session may take 30-90 minutes.

Orientation

Here is an outline of what is in this session. You can click on the hyperlinks to go directly to a section or scroll down below the outline to see all section content.

Section	Content
What is TeamSTEPPS®?	Review short narrative with description of TeamSTEPPS® Watch video TeamSTEPPS® Overview Video Watch video Sue Sheridan Video on Patient Safety
Activity #1	Debrief using discussion questions after watching the video Sue Sheridan Video on Patient Safety
The Importance of Teamwork and Communication	Review short narrative on high-performing teams Read the Joint Commission’s review of the root causes of sentinel events Access the Office of Inspector General report Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries
What skills does the TeamSTEPPS® Framework enhance?	Review short narrative on the four skills involved in TeamSTEPPS®
Activity #2	An activity that helps convey key principles and strategies of teamwork and communication
What specific tools and strategies can be used to make your team more effective?	Review short narrative Learn about the following tools: 1. Situation Background Assessment Recommendation (SBAR) - Activity #3 - Read scenario; practice writing an SBAR 2. Checkback 3. Handoffs - Activity #4 - Discussion questions about handoffs 4. I PASS the BATON 5. Briefs 6. Huddles 7. Debriefs - Activity #5 - Discussion questions about briefs, huddles, and debriefs 8. CUS - Activity #6 - Discussion questions about using the communication techniques covered in this session
Take Home Messages	Review short narrative
Optional Tools and Resources	Access additional tools and resources on TeamSTEPPS®

What is TeamSTEPPS®?

TeamSTEPPS® stands for Team Strategies and Tools to Enhance Performance and Patient Safety.

TeamSTEPPS® is:

an evidence-based framework aimed at optimizing patient and/or resident care by improving communication and teamwork skills in healthcare settings;
another component to help support and enhance person-centered care by promoting the delivery of quality and safe care;
part of the ongoing patient safety movement which includes those receiving care across healthcare settings, including those living in nursing homes; and
focused on specific skills supporting team performance principles and concepts, and provides specific tools and strategies for improving communication and teamwork, reducing chance of error, and providing safer care.

Watch this video titled TeamSTEPPS® Overview Video, presented by Jim Battles, PhD, former TeamSTEPPS® Director, Agency for Healthcare Research and Quality (AHRQ) (1:46).

This video provides an overview of TeamSTEPPS® and also highlights several success stories of healthcare organizations that are using TeamSTEPPS®.

Watch this video titled Sue Sheridan Video on Patient Safety, presented by Sue Sheridan, MIM, MBA, Spokesperson, World Health Organization’s World Health Alliance for Patient Safety (9:49).

In this video, Mrs. Sheridan shares her personal story, which highlights why resident safety is so important and how teamwork can make the difference between life and death.

Activity #1

Discussion questions: Debrief after watching the video Sue Sheridan Video on Patient Safety to help you make connections to work in your organization. Discuss the following questions:

Can you think of an example in your nursing home where communication was inadequate and led to a mistake or resident harm?
Have you thought about ways to improve your communication processes or systems to help staff provide the right information at the right time in order to avoid that mistake from happening again?

The Importance of Teamwork and Communication

Quality of life and quality of care for people living in your nursing home are influenced by the teamwork of your staff — how well they communicate and work together. An effective, well-functioning team structure promotes teamwork and creates a climate based on a commitment to collaboration, mutual accountability, acknowledgment, recognition, and professional respect.

As a result of team competencies, teams can become high-performing. This training will touch on the many interrelated aspects of high-performing teams. Generally speaking, high-performing teams have some common traits. Click on the image below to download and print the list of traits.

A patient safety event that reaches a patient and results in death, permanent harm, severe temporary harm, and intervention required to sustain life is called a sentinel event.

Data from the Joint Commission’s review of the root causes of sentinel events in hospitals shows that breakdowns in communication are identified as a root cause in the majority of events. For example, in 2015, of 936 reported events, communication breakdown was identified as the root cause or one of the root causes for 744 of those events. When the Joint Commission analyzed the root causes of different types of events, communication breakdown was the most commonly identified root cause for events related to delay in treatment, elopement related issues, infection related events, and transfer related events. While these data are from hospitals, nursing homes share some common issues and challenges related to communication and teamwork. Click here to read more from the Joint Commission.

The February 2014 Office of Inspector General report titled Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries found that 22% of Medicare beneficiaries experienced adverse events during skilled nursing facility (SNF) stays, and 11% experienced temporary harm events. 59% of these were determined to be clearly or likely preventable, and of note, 70% of C. difficile-related harm was determined to be preventable.

You have the opportunity to prevent adverse events in long-term care.

What skills does the TeamSTEPPS® Framework enhance?

TeamSTEPPS® consists of four skills:

Communication: Process by which information is clearly and accurately exchanged among team members
Leadership: The ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources
Situation monitoring: Process of actively scanning and assessing situational elements to gain information or understanding or to maintain awareness to support functioning of the team
Mutual support: The ability to anticipate and support other team members' needs through accurate knowledge about their responsibilities and workload

This diagram demonstrates the four teachable-learnable skills that are at the core of the TeamSTEPPS® framework (click on the diagram to download and print it):

The red arrows represent the effect that the four skills and the team-related outcomes have on each other.
The circle around the four skills represents the patient and/or resident care team made up of all who play a supporting role.
Knowledge: Teams that consist of team members with strong leadership, situation monitoring, mutual support, and communication capabilities yield important team outcomes like a shared awareness about what is going on with the team and progress toward its goal. Team members will also be familiar with the roles and responsibilities of their teammates.
Attitudes: When you work in teams in which the members possess good leadership, situation monitoring, mutual support, and communication skills, team members are more likely to have a positive experience; you will enjoy working in teams and trust the intentions of your teammates.
Performance: You'll be able to adapt to changes in the plan of care. Team members will know when and how to back up each other. You'll be more efficient in providing care; you will have a plan; and you will know who is supposed to do what and how they are supposed to do it. Finally, your team will be safer, allowing the team to more readily identify and correct errors, if they occur.
The interrelationships are the foundation of a strong continuous improvement model. The knowledge, skills, and attitudes of teamwork will complement clinical excellence and improve resident outcomes by using feedback cycles and clearly defined tools to communicate, plan, and deliver better quality care.
No amount of teamwork can compensate for clinical/technical proficiency. The foundation of teamwork builds on technical proficiency and protocol compliance.

Activity #2

The Marshmallow Challenge

Try this fun activity that helps to convey key principles and strategies of teamwork and communication. The goal is to build the tallest free standing structure with these materials. This activity takes 20 minutes for instructions and team challenge, followed by 15-20 minute debrief.

For further instructions: PDF

What specific tools and strategies can be used to make your team more effective?

Using TeamSTEPPS® tools and strategies can help you to improve teamwork and communicate effectively and can reduce the potential for error.

These next few sections will cover:

Situation Background Assessment Recommendation (SBAR)
Checkback
Handoffs
I PASS the BATON
Briefs
Huddles
Debriefs
CUS

Situation Background Assessment Recommendation (SBAR)

SBAR was developed in the military to help people get right to the point and provide a clear assessment and recommendation – “We are being attacked, surrounded on all sides, send help now.”

SBAR provides a standard framework to communicate about a situation which needs attention or action and was designed to reduce errors associated with miscommunication or lack of information.

Situation: What is happening with the resident?
Background: What is the clinical background?
Assessment: What do I think the problem is?
Recommendation: What would I recommend?

Watch this video titled SBAR Video (1:10).

Activity #3

Review the SBAR form (available as a PDF or Word document), which can be used to support the communication process (created as part of the Minnesota Antimicrobial Stewardship Program Toolkit for Long-Term Care Facilities).

Practice using SBAR: Read the following scenario. Then individually or in small groups (3−5 people), write an SBAR using information provided in the scenario. Add information to the scenario if you feel it is needed.

Scenario:

Mary, 80 years old, is being admitted to the nursing home for rehab following a hospital stay for septic bursitis, with many complications arising from surgery and treatment for that. The nurse admitting Mary notices that Mary has had three episodes of diarrhea since she arrived six hours ago. The nurse is concerned about the cause of the diarrhea, knowing that Mary has been on antibiotics, and wonders if a potential cause could be C. difficile. She is preparing to call the physician.

Action items: Individually or in a small group, draft the SBAR. Then share with others participating in this session. Discuss what elements made your SBAR effective. What might improve it?

Elements of a successful SBAR would include…

The nurse identified herself and the reason she was calling.
The physician was quickly made aware of Mary’s situation (three episodes of diarrhea in six hours).
The nurse provided the background of the recent transfer, septic bursitis, that there are other complications, and that Mary is on antibiotics. The recent assessment led the nurse to call the physician with her concerns.
The nurse initiated a recommendation for additional labs, and a plan was discussed for future care.

Additional notes: When speaking with SBAR, one does not have to actually say, “S – situation, I am calling…” Begin with at least two identifiers (e.g., your name, the resident's name, where you are calling from) in the process. End communications with:

What questions do you have for me?
I am here until (insert time).
If you need to reach me you can do so by (insert contact information).

Checkback

A checkback is a closed-loop communication strategy used to verify and validate information exchanged. This communication strategy may be effective following an SBAR. Click on the image below to download and print it.

The checkback strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.
Typically, information is called out anticipating a response on any order that must be checked back.
Many communication errors are the result of the sender miscommunicating something or the receiver hearing or understanding something that was different than what was intended. The checkback technique is a great way to ensure both parties agree on what was stated.

Watch this video titled Checkback Video (0:36).

Here are two examples of a checkback:

Example 1:

Physician: Let’s give Metronidazole 500 mg PO three times a day for C. difficile infection, for 14 days.

Nurse: Ok, we will give Metronidazole 500 mg PO three times a day, starting today for 14 days.

Physician: Yes, that is correct.

Example 2:

Physician: Give Septra DS one tablet twice a day for seven days for urinary tract infection. Check INR two days after starting Septra DS and call my office with the results.

Nurse: Ok, that is Septra DS, that is double strength, one tablet twice a day for seven days, and check INR two days after starting the med, and we will call your office with results.

Physician: Correct.

Handoffs

Another time where a standard communication technique is helpful is during transitions of care. Examples of transitions of care include:

when a resident moves from your organization to another (such as a hospital or home care), or
when a team member within your organization is temporarily or permanently relieved of duty (such as during shift changes or when a resident goes to therapy).

Handoffs are used to transfer information (along with authority and responsibility) during transitions in care and to have an opportunity to ask questions, clarify, and confirm information.

Handoffs include the transfer of knowledge and information about the degree of uncertainty (or certainty about diagnoses, etc.), response to treatment, recent changes in condition and circumstances, and plan, including contingencies ("if this happens, then this is what we will do…"). In addition, both authority and responsibility are transferred. Lack of clarity about who is responsible for care and for decision making has often been a major contributor to medical error (as identified in root cause analyses of sentinel events and poor outcomes).

A handoff can also be used in nonclinical settings and departments. For example, at shift change a worker could share information about the status of tasks completed, pending, and those requiring action with the next person responsible for the duties.

Activity #4

Discussion questions:

When do you typically use handoffs? How are handoffs handled on your unit or department?
Do you use standardized forms for any of your handoffs, such as a 24-hour report that includes information on the resident's status or a hospital transfer form?

I PASS the BATON

"I PASS the BATON" is a mnemonic to aid in remembering specific information to include during a handoff.

I = Introduction: Introduce yourself and your role/job (and resident if he/she is present).

P = Patient: State the resident’s name, identifiers, age, sex, and location.
A = Assessment: State the presenting chief complaint, vital signs, symptoms, and diagnosis.
S = Situation: State the current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment.
S = Safety concerns: State critical lab values/reports, allergies, and alerts (falls, isolation, etc.).

the

B = Background: State comorbidities, previous episodes, current medications, and family history.
A = Actions: What actions were taken or are required? Provide brief rationale.
T = Timing: State the level of urgency and explicit timing and prioritization of actions.
O = Ownership: Who is responsible (nurse/doctor/team)? Include the resident/family responsibilities.
N = Next: What will happen next? What are the anticipated changes? What is the plan? Are there contingency plans?

Watch this video titled I PASS the BATON Video (1:26).

Briefs

Briefs are a strategy for sharing the plan when leading a team. During a brief, which is sometimes referred to as a team meeting, the following information should be discussed:

Team membership and roles
- Who is on the team and who is the designated team leader
Clinical status of the team's residents
- The current condition, diagnosis, and status of each resident assigned to the team
The plan of care for each of the team's residents
- What is to be accomplished, what are the expected outcomes, and who is to do it
Issues affecting team operations
- Resources normally available that may be restricted during the current shift

Defining clear goals and a plan to achieve those goals is an important part of the brief, as well as establishing clear roles and expectations for each team member. Successful teams measure their effectiveness in terms of how well they are performing against the established plan. The designated team leader usually conducts the brief, and team members actively participate.

Conducting a brief at the beginning of a shift provides an ideal forum for communicating with other team members about the goals for each resident and the plan of care to ensure patient/resident safety.

Click on the image below to download and print the checklist.

Huddles

A huddle is a tool for communicating adjustments to a plan of care that is already in place. It is an ad hoc meeting to touch base about a change with the resident or team membership or aspects of the current plan that are not working. It is important that such changes are quickly and effectively communicated so the team members all know the plan for providing the best care for the resident.

Huddles are helpful in communicating critical issues and emerging events, assigning resources, and expressing concerns.

Watch this video titled Huddle Video for an example of an effective huddle (you will need to download Windows Media Player to watch this video) (0:25).

Debriefs

Research has shown that teams who effectively debrief their own performance can improve their teamwork in real time.

Debriefs include:

accurate recounting and documentation of key events;
analysis of why the event occurred, what worked, and what did not work;
discussion of lessons learned and how the team can alter the plan for the next time;
reinforcement of what went well and how the team can repeat the behavior or plan the next time; and
establishment of a method to formally change the existing plan to incorporate lessons learned.

Debriefs are most effective when conducted in an environment where honest mistakes are viewed as learning opportunities. Debriefs can be a short (about three minutes or less) team event, typically initiated and facilitated by the team leader.

A checklist can be used by the team during a debrief to ensure that all information is discussed. Click on the image below to download and print the checklist.

Here are two guidelines for conducting debriefs:

Facilitate the discussion as a leader by asking questions related to team performance. For example, questions might include: What did we do well? What did not go well that we can improve?
Recap the situation, background, and key events that occurred. Similar to the brief, the team leader should cover the items on the debrief checklist. The checklist can be used by the team during a debrief to ensure that all information is discussed. The team leader should then summarize lessons learned and set goals for improvement.

It can be helpful to think of a sports analogy when thinking about briefs, huddles, and debriefs. Most everyone has some experience with participating in or watching sporting events. Can you imagine a baseball or football team taking the field without having a game plan, without knowing what everyone’s role and responsibility was, and what they were going to do to try to win? Then they huddle during games to assess how it is going and what they need to do differently. After each game, they debrief. They may even watch film to help them assess what they did well, what they could do differently, or what they need to improve.

Activity #5

Discussion questions: Take a moment to reflect on how your team is currently using briefs, huddles, and or debriefs.

What is working well?
What could be improved?

CUS

Using the CUS technique provides another framework for conflict resolution, advocacy, and mutual support. Signal words, such as "danger," "warning," and "caution" are common in the medical arena. They catch the reader's attention. "CUS" and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue. The use of the CUS words should trigger recognition of the need for further conversation – the need to stop and have discussion to resolve concerns in order to prevent an error or problem.

First, state your concern.
Then, state why you are uncomfortable.
If the conflict is not resolved, state that there is a safety issue. Discuss in what way the concern is related to safety. If the safety issue is not acknowledged, a supervisor should be notified.

A few other phrases that may be helpful include:

I would like some clarity about…
Would you like some assistance?

Here are two examples using CUS:

Example 1:

Nursing assistant to nurse: I'm concerned that Ms. L is not her usual self. She is behaving so differently today. Will you check on her?

Example 2:

Nurse to prescribing practitioner: I’m concerned about the order for levofloxacin for Ms. C’s urinary tract infection. I wanted to make sure you had received a copy of the culture and sensitivities. It looks like the organism is sensitive to a lot of antibiotics, and we have been trying to avoid the use of broad spectrum antibiotics except where absolutely necessary. Do you think one of the other antibiotics on the list would be more appropriate?

Review the CUS tool (available as a PDF or Word document), which can be used to support the communication process (created as part of the Minnesota Antimicrobial Stewardship Program Toolkit for Long-term Care Facilities).

Activity #6

This session covered checkbacks, handoffs, I PASS the BATON, briefs, huddles, debriefs, and the CUS technique.

Discussion questions:

Which one or two strategies/tools (that you are not already using systematically) do you think would be most helpful to use in your organization?
What are the next steps to develop a plan for how you will train staff on the strategies that you would like to begin using?
How will you personally start to use these strategies, as an example for others to follow?

Take Home Messages

TeamSTEPPS® framework is comprised of four teachable-learnable skills: communication, leadership, situation monitoring, and mutual support.
Healthcare teams that communicate effectively and support each other can reduce the potential for error.
Teamwork is not innate. We must learn how to be effective team members. Using TeamSTEPPS® tools and strategies can help us to improve teamwork.

Optional Tools and Resources

Our Iceberg Is Melting by John Kotter and Holger Rathgeber

This is a short book with a powerful message about the fear of change and how to motivate people to face the future and take action.

Build a Tower, Build a Team by Tom Wujec (6:51)

Watch this TED talk presented by Tom Wujec. In the video, Wujec discusses research on the "marshmallow problem."

TeamSTEPPS® 2.0

TeamSTEPPS® is a teamwork system that offers a powerful solution to improving collaboration and communication within healthcare facilities, including comprehensive curricula and instructional guides with case studies and videos illustrating teamwork opportunities and successes.

TeamSTEPPS® 2.0 Curriculum for Long-Term Care

This version of TeamSTEPPS® has been adapted to address issues specific to nursing homes.

TeamSTEPPS® 2.0 Pocket Guide (a quick reference to TeamSTEPPSⓇ tools and principles that includes team structure and four teachable-learnable skills), is available in several forms:

A PDF version of AHRQ’s Team STEPPS pocket guide is available here: https://www.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf

An app available for download is available here: https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguideapp.html

Printed pocket guides, in packs of 10, are available for purchase from AHA Team Training here: https://ams.aha.org/EWEB/DynamicPage.aspx?WebCode=ProdDetailAdd&ivd_prc_prd_key=0c743411-d158-43a3-8804-7ee16f291538

TeamSTEPPS® Long-Term Care Implementation Guide

TeamSTEPPS® Initiative Implementation Guide provides guidelines, tools, and resources for completing each phase and for gathering data necessary for progression to the next phase.