Quality Care Collaborative Learning Series
TeamSTEPPS® in LTC: Communication Strategies to Promote Quality and Safety
Specific to long term care; the information features communication strategies to promote quality and safety. It is designed to help guide nursing home staff in teamwork and communication using specific evidence-based tools and strategies which is a part of TeamSTEPPS® 2.0. The information 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.
How can you use this information?
The information was developed for nursing home leaders that want to optimize team performance by enhancing competency in teamwork and communication. Review the content and decide which components would be helpful to include in educating other staff. The information focuses on selected strategies and tools to enhance teamwork, communication, and resident safety.
What is TeamSTEPPS®?
TeamSTEPPS® stands for Team Strategies and Tools to Enhance Performance and Patient Safety.
- an evidence-based framework aimed at optimizing 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 resident safety movement which includes those receiving care across healthcare settings 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.
The Importance of Teamwork and Communication
Quality of life and quality of care for people living in nursing homes are influenced by the teamwork of the 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. The information touch on the many interrelated aspects of high-performing teams. Generally speaking, high-performing teams have some common traits.
A resident safety event that reaches a resident 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.
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.
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
Four skills that are at the core of the TeamSTEPPS® framework
- 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 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.
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; they include:
- Situation Background Assessment Recommendation (SBAR)
- Check back
- I PASS the BATON
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?
A check back is a closed-loop communication strategy used to verify and validate information exchanged. This communication strategy may be effective following an SBAR.
- The check back 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 check back technique is a great way to ensure both parties agree on what was stated.
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.
I PASS the BATON
"I PASS the BATON" is an 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.).
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?
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 resident safety.
A huddle is a tool for communicating adjustments to a plan of care that is already in place. Huddles are helpful in communicating critical issues and emerging events, assigning resources, and expressing concerns. 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.
Research has shown that teams who effectively debrief their own performance can improve their teamwork in real time.
- 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.
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.