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TEAMSTEPPS 05.2Mod 1 05.2 Page 2 Page 2
Simulation
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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Simulation
Course Outline
Phase 1. Scenario Development Exercise
Phase 2. Measurement Development Exercise
Phase 3. Debriefing
Lessons Learned
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Simulation
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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Simulation
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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Simulation
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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Simulation
EBATEvent-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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Simulation
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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Simulation
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
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Simulation
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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Simulation
Learning Objective: Uses two-challenge rule or CUS to advocate for a patient in labor experiencing frequent, strong contractions
Example Objective
Communication
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Simulation
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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Simulation
TeamSTEPPS Scenario 86
Sally Rodgers, a 25-year-old nullip in labor at term who is dilated 3 cm. This is
a change from 2cm 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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Simulation
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 2cm 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.
TEAMSTEPPS 05.2Mod 1 05.2 Page 15 Page 15
Simulation
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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Simulation
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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Simulation
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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Simulation
Trauma ExamplePre-Hospital/Transport
Trauma PhaseEvent Set
TriggersExpected 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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Simulation
Trauma ExamplePrimary Survey
Trauma Phase TriggerExpected 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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Simulation
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
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Simulation
Develop Measures
1. Consider level of analysis
2. Clarify purpose
3. Decide what to measure
4. Select a measure
Phase 2
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Simulation
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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Simulation
Individuals MD
Nurse
Anesthesia
Teams Delivery team
C-Section team
Multi-team – Team Structure Core team
Contingency team
Administrative team
Consider Level of Analysis
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Simulation
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
Clarify the Purpose
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Simulation
Outcomes tend to be more quantifiable and answer the question “What happened?”
Processes answer the question “Why did it happen?”
Decide What to Measure
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Simulation
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)
Outcomes
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Simulation
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
Process
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Simulation
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
Measurement Tips
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Simulation
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
Select a Measure
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Simulation
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
Checklist Tips
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Simulation
NoYes
Assess Airway
Breathing
Circulation/FAST Exam
Action/Behavior
Disability
Exposure and Environment
Checklist
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Simulation
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
Frequency Count Tips
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Simulation
Two-Challenge
CUS
Task Assistance
Check-back
Call-outs
SBAR
Unintelligible Communications
Communication
Mutual Support
Positive Instances
Positive Instances
Frequency Count
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Simulation
1. The team leader assigned roles to the Trauma Team.
2. The PGY2 used check-back to confirm orders.
Strongly Disagree
Strongly Agree
1 2 3 4 5 6
IneffectiveVery
Effective
1 2 3 4 5 6
x
x
Graphic Rating Scale
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Simulation
Communication: Used check-back during trauma resuscitation.
x
Did not use
check- back
1 2 3 4 5Used
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
Anchored Rating Scale
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Simulation
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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Simulation
Measures
Develop a measure to assess performance for the scenario you
developed earlier
Be prepared to present your measures
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Simulation
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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Simulation
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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Simulation
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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Simulation
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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Simulation
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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Simulation
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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Simulation
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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Simulation
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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Simulation
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