Name
#171 - A Pilot Implementation of the National Center for Patient Safety Team Training Program
Date & Time
Tuesday, February 13, 2024, 12:00 PM - 7:00 PM
Description

According to the Joint Commission, breakdowns in communication continue to be the leading factor contributing to sentinel events across healthcare. A common theme throughout the patient safety literature for focused improvements is effective teamwork, collaboration, and communication among healthcare members. The National Center for Patient Safety (NCPS) Team Training reviews behaviors from Crew Resource Management (CRM) used in the aviation industry and includes tools such as Safety Briefings, the Effective Followership Algorithm, and Situational Awareness. Team Training emphasizes teamwork, threat and error management, and blame-free discussion of human errors. Team Training is an 8-hour interactive class that gives participants the opportunity to practice the learned skills with their team members. The program also includes a requirement for a Unit Based Safety Initiative, a small-scale project identified by each unit and then implemented over a 9 to 12-month period. Prior to facility-wide implementation, we created a list of all the clinical units and support services across the medical center and grouped them into clusters of 5-7 units/departments called waves. Each wave was assigned a 6-week timeframe to complete Team Training activities. Activities included employees in each wave completing the 8-hour Team Training class and subsequent implementation of the selected Unit Based Safety Initiative. The Team Training program implementation was paired with the launch of a standardized daily safety huddle process. The safety huddle is one of VHA’s Four Foundational Practices of High Reliability (safety huddles, leader rounding, safety forums, and visual management systems). Teams were given the option of choosing to utilize the daily safety huddle as their Unit Based Safety Initiative or developing their own initiative. Team Training implementation at the Jesse Brown VA Medical Center was initiated in July 2022, with a small pilot wave including two inpatient nursing units (one medical/oncology/remote telemetry unit and one medical-surgical unit) and the radiology department. During this pilot, we offered 12 class dates with varying times to accommodate morning, evening, and overnight shifts. All 3 teams chose to use the daily safety huddle as their Unit Based Safety Initiative. All three units engaged in Team Training with the following compliance rates with the 8-hour training for all unit employees: 84% (5 East), 93% (5 West), and 90% (Radiology). After 12 months of conducting safety huddles with the new standardized process, the following compliance rates were reported for daily huddles: 68.3% (5 East), 84.5% (5 West), and 86.7% (Radiology). The 2023 all-employee survey (AES) results indicated improvements in selected dimensions that align with Team Training for Radiology and 5W. One caveat is that the annual AES is administered in June, less than one year after the start of Team Training and huddle implementation and may not have allowed adequate time to see significant improvements in culture.

Location Name
Prince Georges Exhibit Hall A/B
Content Presented on Behalf of
VHA/VA
Learning Outcomes
1.Describe the NCPS Team Training program and the topics emphasized in this training.<br />
2.Explain how Safety Huddles promote and sustain the behaviors and tools coached in the Team Training curriculum.<br />
3.Describe the impact and outcomes of the Team Training program on the pilot sites.
Session Type
Posters