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Feature: TeamSTEPPS® and High Reliability: An Overview of the 2016 National TeamSTEPPS Conference

Ms. Heidi King, chief of the Patient Safety and High Reliability Initiatives Office, at the 2016 TeamSTEPPS® National Conference opening up the DoD two-day  session titled “The“Military Health System (MHS) Across the Globe….Don’t Stop Believing in Zero Harm”. Ms. Heidi King, chief of the Patient Safety and High Reliability Initiatives Office, at the 2016 TeamSTEPPS® National Conference opening up the DoD two-day session titled “The“Military Health System (MHS) Across the Globe….Don’t Stop Believing in Zero Harm”.

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The 10th Annual National TeamSTEPPSTeam Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based teamwork system designed to improve the quality, safety and efficiency of healthcare. TeamSTEPPS consists of a collection of instructions, materials and tools to help drive a successful teamwork initiative from the initial planning to implementation through to sustainment. The system is designed to improve patient safety using a three-phase approach: Phase I Assessment: Facility determines organizational readiness; Phase II Planning, Training & Implementation: Facility “decides what to do” and “makes it happen;” and Phase III Sustainment: Facility spreads the improvements in teamwork performance, clinical processes and outcomes resulting from the TeamSTEPPS initiative.TeamSTEPPS Conference – an event designed to highlight strategies and techniques to effectively implement and sustain TeamSTEPPS in today’s ever-evolving health care environment – was held 7-10 June, 2016 in Washington, D.C. Welcoming over 700 health care industry professionals and experts, the National TeamSTEPPS conference spotlighted the value of TeamSTEPPS across clinical and non-clinical settings both in the civilian and military space. Addressing a wide range of topics – with over 30 presentations and workshops on subjects ranging from “TeamSTEPPS 101” to “TeamSTEPPS: The Vehicle to Drive your Metrics in the Right Direction,” “The Answer is in the Room: Using TeamSTEPPS to Problem Solve and Reinvigorate Struggling Teams” and “TeamSTEPPS in Times of Transformational Change” – the 2016 TeamSTEPPS National Conference provided attendees the ability to delve into the TeamSTEPPS framework and its application into all aspects of health care and patient safety. (Visit the AHRQ website to access information and materials from the event.)

Each and every topic covered throughout the National Conference was of extreme relevance to not only civilian health care experts but also Military Health System (MHS) patient safety professionals who continue to make strides towards high reliability by learning growing and implementing patient safety best practices to improve the care we deliver. To that end, the National Conference opened with a Department of Defense (DoD) session (7- 8 June) with approximately 80 DoD TeamSTEPPS experts and champions in attendance from all Services and the National Capitol Region Medical Directorate (NCR MD).

Image highlighting the characteristics of a High Reliability Organization (HRO) needed to create a culture of safety.This year, the theme of the DoD session was “The Military Health System (MHS) Across the Globe… Don't Stop Believing in Zero Harm”. The focus of the session was on leveraging TeamSTEPPS to accomplish the aims of High Reliability Organizations (HROs), leadership development and learning organizations. There were presentations from the High Reliability Collaboration Board (HRO experts from the Services, the Defense Health Agency (DHA) and the NCR MD) illustrating plans for and progress toward high reliability and the role of TeamSTEPPS in that journey. In addition, there were multiple briefings and discussions from the Services and Military Treatment Facilities (MTFs) on how they have leveraged TeamSTEPPS successes and lessons learned to improve patient safety and quality. TeamSTEPPS experts from the DoD also presented several sessions at the National conference. (Visit the PSLC Home Page to access all DoD TeamSTEPPS National Conference presentations.)

Events such as the National TeamSTEPPS conference are, indeed, of great relevance to MHS staff and patients. This is because both the implementation and sustainment of TeamSTEPPS are closely connected to the MHS journey towards high reliability. In fact, the concept of teamwork fits perfectly into the HRO framework because well-trained operational teams:

  • Continually scan their environments for clues of emerging problems
  • Constantly communicate to share information across team members
  • Swiftly adapt to changing demands
  • Continually learn through structured debriefs and real-time collaborative problem-solving
  • Defer to those with the most expertise regardless of hierarchy
  • Drive safety culture by maintaining found mutual respect, trust and accountability for speaking up about identified safety risks and quickly adjusting to contain them

Image of the TeamSTEPPS logo including the principles of TeamSTEPPS.What’s more, when TeamSTEPPS is implemented effectively and consistently, it can both create high reliability and transform an organization’s culture as it:

  • Establishes a common language for discussing “communication” and other teamwork failures
  • Provides simple, teachable tools and techniques that produce high reliability behaviors
  • Levels the professional hierarchy
  • Engages patients and families
  • Gives leaders tools for leading change – to become coaches, mentors and effective team leaders
  • Empowers all staff members to speak up for patients’ safety

TeamSTEPPS invites us to act our way into a new way of thinking to innovate, collaborate to function as high performing teams and provide the highest level of care to our patients and their loved ones. As the table below indicates, examples of how TeamSTEPPS produces HRO practices include:

Image highlighting examples of how TeamSTEPPS produces HRO practices.

As the MHS continues on its path towards high reliability, patient safety champions must continue to be diligent on our focus to mitigate error and identify potential problems by learning from each other and leveraging all the tools at our disposal, especially TeamSTEPPS. After all, TeamSTEPPS is about changing the DNA, revolutionizing the way we provide care by collaborating in innovative ways to eventually achieve zero patient harm.

Learn more about the HRO framework and TeamSTEPPS.

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A decade of progress in Women’s health, cancer research

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10/26/2016
Navy Lt. Cmdr. Denise Thigpen, director, Breast Imaging Center at the Murtha Cancer Center at Walter Reed Bethesda, reads two mammograms of a patient. (Courtesy photo)

New discoveries at the Murtha Cancer Center have researchers encouraged about Women’s cancer research

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Hospital's sterile-processing techs are 'Gladiators' of patient safety

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9/14/2016
Army Staff Sgt. Oscar Domino (left), operating room technician, hands a sterile pack to Army Maj. Jerry Rivera-Santiago, sterile processing's officer in charge. Carl R. Darnall Army Medical Center's Sterile Processing Department assembles and packs more than 400 surgical units monthly. (U.S. Army photo by Gloria Montgomery)

Sterile-processing medical technicians are the multipliers of hospital safety who clean, disinfect and sterilize the hospital and dental clinic's surgical tools

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2016 DoD PSP Awards Application Guidance

Technical Document
8/5/2016

This document provides guidelines for all interested parties who would like to submit an application package for the 2016 Advancement toward High Reliability in Healthcare Awards Program. The awards program recognizes those who have shown initiative and commitment to the development of systems and processes that will lead the MHS toward a better, safer, nationally recognized health care system that all MHS leaders and staff strive for each and every day and one that all patients deserve. Awards will identify efforts that progress the MHS on its journey of continuous improvement, in the areas of Patient Engagement, Healthcare Quality and Safety, and Improved Access.

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MHS Patient Safety Spotlight

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8/1/2016
Image of the DoD Patient Safety Program (PSP) logo.

The MHS Patient Safety Spotlight is a new resource designed to highlight best practices and interesting initiatives that come from the field and are worthy of being shared across the enterprise. This resource features data-driven examples of improvement and case studies that tackle specific problems with specific solutions.

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MHS Patient Safety Data Snapshot

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8/1/2016
Image of the DoD Patient Safety Program (PSP) logo.

The new MHS Patient Safety Data Snapshot is a monthly compilation of two types of patient safety data 1) Sentinel Event (SE) notifications submitted to the Patient Safety Analysis Center (PSAC); 2) Anonymous, voluntarily reported patient safety events via the web-based incident reporting system known as PSR.

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DoD PSP Treasure Chest: August Edition

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8/1/2016
Ensign Joshua Mondloch, a nurse assigned to Naval Medical Center San Diego, takes notes in the cardiology in-patient ward. More than 1,000 active duty and civilian nurses provide patient care throughout the medical center. (Photo by Mass Communication Specialist Second Class John O’Neill Herrera)

Welcome to the August edition of the DoD PSP Treasure Chest! Each and every month, we will be sharing resources to help you execute your day-to-day patient safety activities easily and effectively. Please visit us often and get access to tools and information developed with you, our committed MHS patient safety champions, in mind! This month we highlight the following resources: Patient Activation Resource Guide, Ask Me 3® Brochure, On-Demand e-Learning Courses, and Facebook Page.

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Patient Safety in Action: The I’M SAFE TeamSTEPPS® Checklist – An Exercise in Openness and Transparency with your Team

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8/1/2016
NEWPORT NEWS, Va. (Apr. 14, 2016) -- During a General Quarters training exercise, Sailors assigned to Pre-Commissioning Unit Gerald R. Ford's (CVN 78) medical response team, simulates care and treatment for common injuries. This ship-wide general quarters drill focused on damage control and emergency responses and is a significant step in certifying the crew as they train to fight and take delivery of the ship.(U.S. Navy photo taken by Mass Communication Specialist 3rd Class Matthew R. Fairchild/Released)

The connection between transparency and high reliability is one that touches many aspects of what we do as MHS patient safety professionals. We strive to be transparent in the way we share information with our patients – working with them as partners in their care and informing them of what we do openly and visibly. We are also transparent about our MTFs progress towards high reliability so that we can continue marching towards our goal of zero patient harm with efforts such as the Patient Safety Culture Survey. Another way that we, as MHS patient safety professionals, can display transparency on a daily basis is by using tools such as the I’M SAFE TeamSTEPPS Checklist.

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HRO Corner: The Patient Safety Culture Survey Resource Guide – An Overview

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8/1/2016
Soldiers from the 399th Combat Support Hospital, 804th Medical Brigade, 3d Medical Command (Deployment Support) watch video footage of their performance during an exercise held April 2, 2016 at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota. The unit's every move was recorded at the facility, which allowed them to review and improve their performance throughout the course of the exercise. During the exercise, the unit, which is based out of Fort Devens, Massachusetts, practiced the Team Strategies and Tools for Enhanced Performance and Patient Safety, or TeamSTEPPS, model of patient care. TeamSTEPPS is a framework implemented by the Department of Defense to optimize performance of military medical teams and reduce communication errors that can result in improper patient care. (Photo by: Staff Sgt. Andrea Merritt)

The DoD is on a journey to transform the Military Health System (MHS) into a high reliability organization (HRO) to ensure safe, reliable care for all of its patients and their families. This transformative shift is one that requires a laser-sharp focus by every one of us – leadership and frontline staff – to identify high-risk situations before they lead to an adverse event. To make this possible, prevention and performance improvement must become intrinsic elements of what we do on a daily basis. First, however, we must understand the progress each of our Military Treatment Facilities (MTFs) is making towards the high reliability goal.

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Feature: Transparency, High Reliability and Patient Safety

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8/1/2016
Senior Airman Wesley Hong, 60th Medical Diagnostics and Therapeutics Squadron picture archiving communication system administrator, reviews patient imagery May 25, 2016, at David Grant USAF Medical Center at Travis Air Force Base, Calif. Hong works in the hospital's PACS department, which is the largest in the U.S. Air Force. The department is responsible for ensuring the accuracy of health records for medical facilities at 19 bases, including clinics in Afghanistan. (U.S. Air Force photo by Tech. Sgt. James Hodgman)

On any given day, Military Health System (MHS) patient safety professionals are working tirelessly to ensure they provide the highest quality of care to their patients. Driven by a high level of dedication, MHS patient safety professionals know that our patients are the single most important part of our mission and we must serve our patients in an open and transparent way.

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MHS Leadership Engagement Toolkit

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7/14/2016

The Leadership Engagement Toolkit was designed to help healthcare leaders assess gaps in their safety culture, engage key influencers for change, set goals for targeted improvement, implement proven safe practices, and reinforce key behaviors to ensure high-reliability performance for improvement. There are two sets of evidence-based best practices (“strategies”): Executive Leadership and Frontline Physician Leadership. The practices focus on what the practice is, why it is used, and how to implement it. There is also a "How to Guide" that focuses on getting started, equipping leaders as coaches, and making and measuring progress.

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HRO Corner: Measuring the Effectiveness of the TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ) – U.S. Army Medical Command Implementation

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7/1/2016
The DoD PSP team commends the MEDCOM for its implementation of TeamSTEPPS and the T-TPQ.  It is this type of well-thought out and carefully planned application of TeamSTEPPS that will continue to move MHS forward and towards becoming a high performing, highly reliable health care system.

Offering various ready-to-use tools, materials and resources, TeamSTEPPS can be tailored to address the specific needs of an organization to seamlessly incorporate its principles into all areas of a health care system. In fact, it is only by fully integrating the tools that TeamSTEPPS offers into our day-to-day activities that Military Health System (MHS) leadership, frontline staff and patient safety professionals will truly benefit from leveraging this methodology. A great example of this is the work and research that the U.S Army Medical Command (MEDCOM) conducted regarding the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ). Highlights of this work were presented at the 2016 National TeamSTEPPS conference this past June.

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Patient Safety in Action: The DoD Patient Safety Program Announces the 2016 Quality and Patient Safety Awards

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7/1/2016
Across the Military Health System (MHS) patient safety professionals work arduously to elevate the care they provide to their patients. The 2016 Quality and Patient Safety Awards program recognizes such hard work and relentless focus on delivering excellence every single day.

Every step Military Health System (MHS) patient safety professionals take towards achieving high reliability is worthy of praise and recognition. Today more than ever, our commitment to excellence in our day-to-day activities is absolutely crucial. For this reason, the DoD PSP team is excited to announce that we will soon begin accepting submissions for the 2016 Quality and Patient Safety Awards.

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MHS Patient Safety Spotlight

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7/1/2016
Image of the DoD Patient Safety Program (PSP) logo.

The MHS Patient Safety Spotlight is a new resource designed to highlight best practices and interesting initiatives that come from the field and are worthy of being shared across the enterprise. This resource features data-driven examples of improvement and case studies that tackle specific problems with specific solutions.

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Military Health System (MHS) Patient Safety Culture Survey Update

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7/1/2016
Patient safety professionals across the Military Health System (MHS) work eagerly as teams to deliver excellence and high quality care. By completing the 2016 MHS Patient Safety Culture Survey earlier this year, MHS patient safety champions voiced their opinions and contributed to patient safety improvements in their facilities to optimize the care we provide every day. In this picture, the Army Reserve Medical Command team observes Soldiers of the 399th Combat Support Hospital, 804th Medical Brigade, 3rd Medical Command (Deployment Support) as they conduct an exercise at the Mayo Clinic Multidisciplinary Simulation Center in Rochester, Minnesota. Photo by: Staff Sgt. Andrea Merritt.

Starting in February through mid-April, Military Health System (MHS) staff at Military Treatment Facilities (MTFs) worldwide were asked to complete the 2016 MHS Patient Safety Culture Survey (Culture Survey). The purpose of the Culture Survey was to assess staff perceptions of patient safety at their MTFs.

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DoD PSP Treasure Chest: July Edition

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7/1/2016
Military Health System (MHS) patient safety champions work tirelessly to deliver high quality care to their patients. The DoD PSP Treasure Chest provides you with information, tools and the resources you need to help you execute your patient safety activities effectively and easily. This month, access the SBAR toolkit, the Medical Team Performance Assessment Tool (MTPAT), the Patient Safety Learning Center (PSLC) and the Patient Safety Reporting (PSR) eLearning course.  Photo by: Robert Whetstone.

Welcome to the July edition of the DoD PSP Treasure Chest! This month, we highlight the SBAR toolkit, the Medical Team Performance Assessment (MTPAT) tool, the Patient Safety Learning Center (PSLC) and the Patient Safety Reporting (PSR) eLearning course. Each and every month, we will be sharing resources to help you execute your day-to-day patient safety activities easily and effectively. Please visit us often and get access to tools and information developed with you, our committed MHS patient safety champions, in mind!

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