Facility cuts falls 88% and med errors 30%

Butler County Health Care Center (BCHCC) in David City, NE, is small — it has 25 beds serving a rural community of 2,500 — but the administrators think big. Using a program that enhances teamwork, the hospital has reduced patient falls by 88% and medication errors that reach the patient by 30%.

The improvements came as a result of the free Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program offered by the Agency for Healthcare Research and Quality (AHRQ), which improves communication teamwork.

The effort began as BCHCC was working on a project to reduce medication errors, explains CEO Don Naiberk. "We had had a couple of medication errors that, although they didn't result in harm to the patient, were significant and could have caused harm," Naiberk says. "We really felt like we needed to do something different."

By studying error reports and the results of root cause analyses, the organization learned that poor communication was the most frequent cause of mistakes. The organization's staff needed to find a way to work as a team, not as independent healthcare providers. TeamSTEPPS training was identified as a way to help BCHCC staff overcome communication barriers and improve workplace culture. With that goal in mind, Naiberk and two other hospital leaders — a registered nurse from the outpatient department and the new director of patient safety -— took the master training course offered by AHRQ in 2008.

BCHCC began implementing TeamSTEPPS incrementally. The Surgery Department was among the first, and two TeamSTEPPS tools were introduced there: CUS ("I'm Concerned, Uncomfortable, this is a Safety issue") and the two-challenge rule, which requires assertively voicing a concern at least twice to make sure it is heard. The Magic Wand exercise — in which participants are asked what they would improve in their department if they had a magic wand — was used in the first meeting to help identify safety problems that were rooted in exchanges with other departments and staff members.

After a few sessions, it was evident that a global approach was needed to improve patient safety, Naiberk says.

Training began with supervisors and managers. During a supervisor retreat, TeamSTEPPS fundamentals were taught in a four-hour session. After evaluating this phase of the training, the TeamSTEPPS team realized that more support for TeamSTEPPS was required, so five more master trainers were added, including a member of the medical staff. To increase its effectiveness, training became more interactive, and class size was limited to 14 participants.

A series of two training sessions, each lasting one-half day, for all employees was scheduled during a four-week period to intensify the training and results. Training was held off site to minimize distractions and lend a sense of priority to the sessions. Finally, training groups were implemented across departmental lines. (See the story, below, for details on how TeamSTEPPS was implemented at the hospital.)

All 117 employees at BCHCC have received TeamSTEPPS Fundamentals training, and the hospital regularly offers refresher courses and training for new employees, Naiberk says. There have been numerous improvements as a result, he says. The most prominent improvements were reducing medication errors that reach the patient by 30% and patient falls by 88%, both the result of using TeamSTEPPS tools to identify problems and improve communication, he says.

"The program leads you to identify the underlying issues in any target problem. TeamSTEPPS doesn't by itself solve your patient safety problem, but it gives you the tools to work together and identify those root causes better," Naiberk says. "Staff communicate better, and there don't seem to be the conflicts that we used to have. They're given tools to deal with conflict and avoid having things escalate to the point that administration has to intervene." (For the schedule and other information on TeamSTEPPS, go to http://teamstepps.ahrq.gov.)

Creative ideas keep staff on TeamSTEPPS

Butler County Health Care Center (BCHCC) in David City, NE, has an enthusiastic team of master trainers who provide training and coaching in the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program offered by the Agency for Healthcare Research and Quality, which improves communication teamwork.

Without constant reinforcement and the instilling of the TeamSTEPPS tools as new habits, the old, less desirable habits will return, says CEO Don Naiberk. The master trainers brainstorm to come up with ideas to keep TeamSTEPPS in front of the staff. These were some of their ideas:

• BCHCC has a stuffed penguin mascot named YaYa that travels around the hospital, building situational awareness. He moves to a different location each week and carries a sign that holds the name of a TeamSTEPPS tool or strategy. There is a weekly prize drawing for employees who complete a form listing where they found YaYa, what his message is, and what the message means (how or where can it be used).

There's a bit of excitement and mystery associated with YaYa and a bit of healthy competition in finding him, Naiberk says. The explanation of YaYa's tools have been complete and detailed, showing the staff learned well or are diligently looking in their pocket guides to refresh their memories, he says.

Knowing that poor communication was a major cause of error and confusion in the hospital, another cartoon penguin character, Didga U. Know, was created. His purpose is to alert staff about new policies or other important information. When Didga is posted at building entrances to give staff a heads-up, it is their responsibility to seek out the new information through their supervisors, posted notices, and the hospital's online resources.

Because of remodeling, there is a temporary, unfinished wall in the hospital dining room that was made into a TeamSTEPPS graffiti wall. Its artwork and text reinforce TeamSTEPPS tools and strategies. Staff members are invited to share their team success stories by posting them on the wall.

• A "Play and Learn" TeamSTEPPS session is held the first Friday of every month. Sessions feature a tool or strategy and an opportunity to practice using it. Along with the featured tool, simple team-building exercises are conducted. The Play and Learn is set up in the staff cafeteria during break times, and treats are used to encourage participation.

• BCHCC developed a DVD to introduce TeamSTEPPS to new hires as part of their orientation.It explains the concept of teamwork and the tools and vocabulary of TeamSTEPPS so individuals will understand the team tools when they are used. As new hires are added, they are trained in TeamSTEPPS Fundamentals in group settings. A quarterly Fundamentals training in two four-hour sessions is held to ensure all employees have the same training and understanding of the TeamSTEPPS concepts.