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System Widely Accepted;
Madigan AMC Shares Experience
2006 was a watershed year for medical
team training in the Department of
Defense (DoD) Patient Safety Program
and beyond. TeamSTEPPS, an evidence-
based system developed by the DoD
Health Care Team Coordination Program
(HCTCP) in collaboration with the
Health and Human Services Agency for
Healthcare Research and Quality (AHRQ)
was formally launched in the Military
Health System (MHS) following extensive
pilots. On November 2, 2006 Team-
STEPPS was released to the public
domain. An overview of the Program
confirms a year of growth within the
MHS and in the private sector. TeamSTEPPS training session, taught by John S. Webster, M.D., Lauren Toomey,
Senior Program Analyst, DoD HCTCP Program, and Heidi King, Program Director,
TeamSTEPPS Today…and Tomorrow DoD HCTCP Program.
TeamSTEPPS was developed to provide a
comprehensive curriculum, based on con- specific teamwork behaviors and skills
more than twenty years of research on firms that TeamSTEPPS is enjoying wide- being taught pertinent and immediately
teams and team performance, for use spread attention. “The program offers an useful in their day-to-day practice.
among all three Services. In 2006, the excellent model and thorough instruction
TeamSTEPPS curriculum established on how an institution can alter [its] cul- The TeamSTEPPS vision going forward
more than 300 trainers at twenty-three ture and support enhanced teamwork,” includes the establishment of a robust
Military Treatment Facilities. Working says Dr. Mark V. Williams, professor of online resource to enhance accessibility of
together, AHRQ and DoD are engaged in medicine at Emory University, who is the program materials and other HCTCP
an extensive awareness campaign targeted evaluating TeamSTEPPS for possible use resources. Strengthening ongoing evalua-
at hospitals, hospital associations, health- at Emory. tion and impact of the program is a top
care trade associations, professional priority, as is more fully integrating team-
organizations and medical and nursing Heidi B. King, MS, Director of the DoD work principles and their relational impact
schools. A front page article on Team- HCTCP, reports that, to date, overall reac- with outcome measurements. The effort to
STEPPS in the June 1, 2007 issue of Inter- tion to the TeamSTEPPS program and con- bring teamwork training to multiple ven-
nal Medicine News (Vol 40, No 11, tent has been favorable. Providers find the ues will continue.


3 TeamSTEPPS Award
4 Pediatric Fall Scales
6 Patient Safety Managers Speak Out
TeamSTEPPS IN REVIEW lenges teamwork implementation faces. Indi- good example of how a change team actually
Continued from Page 1 vidual practitioners often misunderstand team works at Madigan. The team met with stake-
training, mistaking increased communication holders, listened to concerns and conflicts,
Madigan Army Medical Center: for an invitation to “mutiny.” Overworked determined whose presence was essential at
A Case Study in TeamSTEPPS providers, who have seen “magic bullets” come briefs, and devised a plan which removed bar-
Implementation and Sustainment and go in healthcare, can be resistant to yet riers to participation. Briefs were scheduled at
As TeamSTEPPS and team training is being another proposed easy answer to complex 7:05 am and pm to accommodate staff and
embraced by MTFs across the MHS, Madigan quality improvement issues. At Madigan, years resident schedules. They are mandatory; any-
AMC remains one of the earliest and most of hard work have been necessary to chip away one who does not appear is called on the spot.
consistent users of teamwork strategies. The at misconceptions such as these. COL Nielsen By painstakingly bridging the gap between
foundation of Madigan's interest in teamwork has consistently emphasized that teamwork is training and doing, Madigan has seen its cul-
was laid when the Emergency Department not about mutiny, but about equipping physi- ture slowly change over the years.
participated in a study of MedTeams, an early cians, who are still responsible for their patients
team training program. This was followed by and who continue to make the final decisions, COL Napolitano currently coordinates the
the involvement of the Labor and Delivery with better, more complete, data. Teamwork is TeamSTEPPS activities at Madigan and is
(L&D) Unit in a 2003–2004 randomized trial not the single answer to quality concerns; largely responsible for the ongoing Team-
to evaluate the effect of team training on out- rather it is one of many tools which together STEPPS training and sustainment. He explains
comes. Their early use of teamwork resonated provide a coherent, integrated approach to that today in the OB/GYN Department the
with the L&D staff, which went on to look for improved patient care. TeamSTEPPS way — with its common lan-
ways to incorporate team training into their guage, formal meetings and accepted strategies
department after the evaluation trial ended. How did teamwork in general and Team- — is the way things are done. He sees the real-
Fortuitous timing brought Madigan together STEPPS in particular become part of the cul- ity of TeamSTEPPS integration reflected in the
with TeamSTEPPS, then in development, and ture of the OB/GYN Department at Madigan? training referrals he has begun to receive. New
Madigan's transition and early commitment COL Nielsen explains that the key to success- OB/GYN providers not tuned in to teamwork
to TeamSTEPPS was made. ful implementation was moving beyond train- or familiar with TeamSTEPPS are told “We
ing and intellectual commitment to opera- don't do business the old way”, and are soon
COL Peter Nielsen, Chief of OB/GYN, and tionalizing the process — physically doing directed to a teamwork training course. To sus-
COL Peter Napolitano, Director of the Mater- things differently to incorporate the elements tain this hard-won teamwork culture, COL
nal-Fetal Medicine Fellowship, are the official of teamwork in the daily routine. In every Napolitano maintains a team of forty-five vol-
champions of TeamSTEPPS at Madigan. COL transition to teamwork, a change team is iden- unteer instructors, who assist him with twice
Nielsen, a participant in the L&D MedTeams tified and tasked with making the principles of yearly training for new staff and annual
trial and an early teamwork user and advocate, team training a reality. The integration of refreshers for all providers. The teamwork cul-
has gained a unique understanding of the chal- teamwork briefs on the OB/GYN floor is a ture is maintained in more subtle ways, as well.
Morbidity and mortality conferences have
been transformed to actionable learning ses-
sions that incorporate TeamSTEPPS strategies
into integrated improvements.

There is evidence that the overall culture at

Madigan is embracing teamwork. Although
TeamSTEPPS gained its foothold in the
OB/GYN Department, its use is spreading to
related areas. The Pediatrics Department has
undergone global training, and Family Med-
icine has been involved in teamwork activi-
ties. Plans are being made to train the Med-
ical Intensive Care Unit in TeamSTEPPS in
the spring of 2008.

The ability to export TeamSTEPPS tools to

operational problems is another indication
that teamwork is permeating the culture at
Madigan. An adaptation of teamwork princi-
ples was used to address a recent increase in
the birth rate and its attendant stress on the
OB/GYN Department. Similarly, the use of
TeamSTEPPS tools has helped Madigan make
Slide from MHS Conference presentation illustrating the reach of TeamSTEPPS integra- hospital-wide changes necessary to cope with
tion in non-teamwork related settings at Madigan AMC. an increase in overall war-related volume.


TeamSTEPPS Integration at Madigan:
Beyond Basics to Simulation Center, Out-
Patient Clinic, Patient-Centered Involvement
From its early-user beginnings, Madigan has
evolved beyond its hospital applications to
new environments.

Early training has begun with outpatient

providers and staff. Moving TeamSTEPPS to
the outpatient OB/GYN clinic has required
adapting teamwork principles and strategies
to a different milieu. Although many of the
healthcare providers are familiar with team-
work on the inpatient floors, new team pat-
terns are being customized to address clinic
interactions and responsibilities.

A pilot study to extend TeamSTEPPS beyond

providers to patients and their families is cur-
rently being conducted at Madigan. This
patient engagement initiative, entitled Patient
and Family Join the Team, addresses Joint
Commission Patient Safety Goal #13, which MAJ (Dr.) Shad Deering, Madigan's Director of Andersen Simulation Center, sets up
encourages patients' active involvement in mobile obstetrics simulator, which combines teamwork and technical proficiency training
their own care as a patient safety strategy. to improve patient outcomes.

The Andersen Simulation Center (ASC) at A particularly innovative approach to com-

Madigan, designated as a Team Resource bining simulation and teamwork training is
Center, is a unique resource which has pro- the SHAD — Simulator for High Acuity
vided a new arena for teamwork training Deliveries — a mobile obstetric simulator TeamSTEPPS Wins Award
and evaluation. Charged with the dual mis- currently being created by the ASC with
sion to support Graduate Medical Educa- funding support from the DoD Patient Safe- TeamSTEPPS recently won the prestigious
tion, nursing and medic training at Madi- ty Program. MAJ Deering hails the SHAD as 2007 M. Scott Myers Award for Applied
gan and to support training for health care a creative response to the concern that up to Research in the Workplace.
professionals across the Western Region forty percent of maternal deaths in the Unit-
Medical Command, the ASC opened in May ed States are potentially preventable and
2002. Utilizing high-fidelity simulations, often related to obstetric care during emer- The Society for Industrial and Organiza-
the ASC hosts training programs ranging gencies, and the related Joint Commission tional Psychology grants the Award “In
from basic medical skills to full-blown trau- requirement that obstetric emergency drills recognition of a project or product repre-
ma scenarios, as well as off-site programs become part of routine training. Incorporat-
during field exercises. One of the goals of ing specific TeamSTEPPS components into senting an outstanding example of the
the Simulation Center is to increase com- the SHAD drills combines individual and practice of industrial and organizational
munication, teamwork and critical thinking team proficiency training in a unique way. psychology in the workplace.”
skills by promoting Crisis Resource Man- “Previous simulations have looked at either
agement training. technical proficiency or the teamwork aspect,
but rarely both. MAMC's mobile OB project Based on well-researched communica-
MAJ Shad Deering, Director of the Simula- incorporates both of these key aspects to tion and teamwork principles of Crew
tion Center at Madigan, explains that for the improve patient outcomes,” Deering Resource Management and High-Relia-
last eighteen months TeamSTEPPS has been explains. With plans to deploy eight SHADs bility Organizations (HROs) the Team-
incorporated into the ongoing simulation to other MTFs, along with training, data col-
training. TeamSTEPPS will also be a part of lection and simulator-customization, expec- STEPPS system is helping to improve the
the standardized simulation curriculum tations are high. “I think we're going to see quality, safety and efficiency of healthcare
being developed for the Army by the Central results on several levels. I expect our nurses — one team at a time.
Simulation Committee (CSC) at the ASC. and our physicians to be more confident
Using a recent grant of $2.88 million dollars, when they experience certain emergencies. I
the CSC will provide simulators and admin- expect our response times to get better. I For more information, visit:
istrative support to train providers in nine expect our communication to get better, and news/documents/Release200611.html.
different specialties in the new curriculum at I expect it to improve patient safety and
ten MTFs, beginning later this year. team-driven care,” says MAJ Deering.


Feedback and Suggestions Based on Your Reporting
PATIENT FALLS facilities and hospitals (Tinetti 2007) reveal anticonvulsants, narcotics, anti-hyperten-
that falls are frequent in the seventy plus age sives are at higher risk.
CONFERENCE group, and that they increase with age. Half
Transforming Research into Practice of all skilled nursing facility residents in Pediatric Fall Intervention
long-term care fall. In the hospital/post-hos- Pursuant to the Joint Commission directives
Pamela Copeland, JD, RN, BSN
pital setting, twenty percent of patients fall on falls, those facilities that service a pedi-
Patient Safety Manager
during hospitalization or within thirty days atric population must include this popula-
The 8th Annual Patient Falls Conference, of discharge. Overall, factors precipitating tion in the overall fall prevention program.
co-provided by the University of South falls include: Immutable predisposing factors Studies conclude that falling is a natural part
Florida College Of Nursing and the James — age, gender, past fall history, demograph- of the growth and development process. The
A. Haley Veterans' Hospital of VISN 8 ic, chronic disease and Modifiable predispos- Joint Commission, after extensive review,
Patient Safety Center of Inquiry was held ing factors — decreased strength, impaired has directed that criteria be developed to
in Clearwater Florida on April 15–18, balance/gait, visual impairment, orthostasis assist in identifying populations of children
2007. The internationally recognized fac- (decreased blood pressure on standing), cog- at risk for harm from falls; that all children
ulty provided lessons-learned, best prac- nitive impairment, foot problems, and should be screened to determine whether
tices and cutting edge research findings for depressive symptoms. Common precipitat- they are in an at risk population; and that
patients at risk for mobility-related ing events in any setting include: stairs, trip- any child who is in an at risk population
adverse events. ping hazards, toileting, devices and medica- should be assessed and protected. There are
tions. Hospital inpatients with low hemat- numerous pediatric predictive fall scales in
Research Findings ocrits; devices (IVs, urinary catheters, chest use; however only the GRAF PIF Scale has
Findings from eighty cohort studies of the tubes); multiple medication changes and been validated. See Table 1 for a summary of
community, long-term care skilled nursing medications such as psychotropics, diuretics, pediatric fall scales.
Table 1 Pediatric Fall Scales
Fall Scale Criteria and Scoring Method Scoring Method and Inter-rater Reliability

GRAF PIF (Children's LOS, IV free, PT/OT need, Antiepileptic Logistic Regression — 84% accuracy; moderate
Memorial Hospital, Medication, Ortho-muscular/skeletal risk (1), high risk (2); sensitivity/specificity
Chicago, Ill.) Disorder, Fall Hx (past month or during 75/76%; each item scored 1 point except Fall
this hospitalization) Hx given 2 points

CHAMPS (St. Francis Change mental status/Disorient, History Logistic Regression — 84% accuracy, no
Hospital, Tulsa Fall, Age less than 36 months, Mobility report sensitivity/specificity; presence of any
Oklahoma) Impairment, Parental Involvement, Safety item-high risk

Humpty Dumpty Fall Diagnosis & Age Driven; All Respiratory Any patient within these categories is
Prevention (Miami & Neuro Patients; Adolescents with Neuro automatically high risk. No sensitivity/
Children's Hospital) Disorders and All Children less than specificity data provided. Report program
36 months has demonstrated 28% decrease

Cumming's Scale Fall Hx, Physical Function, Cognitive/ Each item scored 0-2 or 3, > or equal to
(Phoenix Children's Psych Impairment, Equipment Need, 8 = high risk; no data on sensitivity/
Hospital) Medication Altering Equilibrium specificity or effectiveness provided

I'M SAFE (Denver Impairment (PT/OT involved), Medication Each item score 1 point except Medication
Children's Hospital) (seizure, narcotics, epidurals), Sedation, & Sedation given 2 points. Total score —
Admitting diagnosis (Neuro/Ortho), no risk (0), moderate risk (1), or high risk (2).
Fall History, Environment Care (restraints, No report of sensitivity/specificity data
IV, foley, RN

Graff (2007)


Feedback and Suggestions Based on Your Reporting
Overcoming Barriers patients who decline
Conference experts agreed that the health- • Involve the family/caretaker
care industry has not adequately • Implement visual monitoring devices
addressed the issue of falls. The tendency (Consider adding surveillance to
has been to lump all falls into a single cat- HIPAA policy and general hospital
egory, without regard to causation or to consent)
the characteristics of the different at-risk • Assess environment for fixtures
populations involved. To improve existing (toilets/grab bars, showers, stretchers,
fall prevention efforts, attendees were beds, chairs) that may not accommodate
urged to develop fall categories that reflect obese patients; develop contingency plan
causality and to more conscientiously dis-
tinguish between screening for falls and Communicate
actually assessing a particular patient's • Utilize S-Bar when communicating
risk of falling. with patient/family about fall preven-
tion; e.g. “Mr. Garcia I am your nurse
Champions of patient fall prevention pro- today. You are at risk for falls. You can
grams must be innovative in motivating staff hurt yourself. You can crack your head,
to maintain fall reduction vigilance. Key rec- break your hip and this will delay your
ommendations are: hospital stay. Please contact me when
you need to go to the bathroom.”
Keep fall prevention an active and visible topic (Hendrich,A. (2007) Targeted Interven-
• Make fall prevention a routine part of tions: Transforming Fall Prevention Prac-
patient care conferences and shift reports tices. 8th Annual Transforming Fall Pre-
TeamSTEPPS SBAR card, illustrating SBAR
• Include fall prevention at facility safety vention Practices, Clearwater Florida,
communication model for providing
fairs April 2007. patient information. SBAR ensures com-
• Partner with family/care takers • Ensure that multidisciplinary team plete information transfer, and provides
• Require teach back demonstrations when receives updates on patient fall status the receiver a structure for remembering
teaching family/patients fall prevention and interventions the details that they heard.
• Incorporate ancillary services in
patient fall prevention discussion Summary
Continuous quality improvement entails References
Engineer processes that foster staff compliance evaluating current practices for relevance 1. Graf, E. (2007). Inpatient Pediatric Fall
• Incorporate visual indicators such as and efficacy. Patient fall prevention is con- Assessment & Interventions: What we Know so
signs and color-coding stantly evolving as evidence-based research Far. 8th Annual Transforming Fall Prevention
• Develop a bag of interventions and place provides new information. The substantive Practices, Clearwater Florida, April 2007
it in the room for at risk fall patients components of a credible and effective 2. Nelson, A. Cracking the Code for Patient
• Place fall prevention supplies in the patient fall program include screening, Falls. 8th Annual Transforming Fall Prevention
unit's main area assessment/re-assessment, interventions Practices, Clearwater Florida, April 2007
geared to subpopulations and individual- 3. Scott, V. Policy and Program Impact to
Encourage staff to fashion solutions ized plans, continuing education, evaluat- Reduce Harm from fall. 8th Annual Transform-
• Conduct admission huddles to deter- ing and communicating program ing Fall Prevention Practice,. Clearwater Flori-
mine patient's fall risk; discuss cus- progress/effectiveness. Consider using the da, April 2007
tomized interventions information provided above as you address 4. Smith, L. Celebrating Success Reducing Fall
• Conduct non-accusatory post-fall hud- the 2008 National Patient Safety Goal #9B and Harm from Falls. 8th Annual Transforming
dles to discuss intervention “next time” — implement a fall reduction program Fall Prevention Practices, Clearwater Florida,
including an evaluation of the effectiveness April 2007
Customize Patient Fall Interventions of the program. Doing so will enable your 5. Tinetti, M Fall Prevention: Research and
• Develop fall prevention programs for program to evolve and will transform the Interventions for Older Populations. 8th Annu-
subpopulations (amputee, wheelchair effectiveness of fall prevention practices al Transforming Fall Prevention Practice,.
dependent patients, neuropathy, obesi- within your facility. Clearwater Florida, April 2007.
ty) and tailor individualized plan based
on unique needs
• Be proactive with toileting; make rou-
tine rounds; return randomly for


DoD PATIENT SAFETY Patient Safety Program Director COL feedback from their PSM attendees. The
Steven Grimes began with a welcome and US Army Medical Command has begun
PROGRAM WORKSHOP overview of the PSP organizational struc- an initiative to standardize the approach
Patient Safety Managers Provide ture and future plans. Leaders of the three to inpatient medication reconciliation,
Input, Share Experiences PSP components followed with reviews and has renewed its commitment to the
and updates of their respective programs. TeamSTEPPS program. On the PSP level,
Ms. Heidi King, Director, Healthcare Team key ideas have been synthesized and
In early May, over fifty patient safety man- Coordination Program (HCTCP) dis- action steps are being developed. CERPS is
agers (PSMs) from the three Services cussed TeamSTEPPS; Dr. Eric Marks, currently re-evaluating the training cours-
attended the first DoD Patient Safety Pro- Director, Center for Education and es for PSMs; HCTCP will continue to
gram (PSP) workshop, following the Research in Patient Safety (CERPS) out- modify and improve the sustainability of
National Patient Safety Foundation's annu- lined training and education for patient TeamSTEPPS; and the PSC is actively
al congress in Washington D.C. The goal of safety managers; and Dr. Geoffrey Rake, seeking to improve the timeliness and
the workshop was to provide an opportu- Director, Patient Safety Center (PSC) accessibility to data and products.
nity for PSMs, PSP leadership, and Service reviewed data collection and PSC products
representatives to discuss issues related to available to the Services and PSP. The PSP is committed to improving the
the DoD PSP, and to share best practices Patient Safety Program, and will continue
and discuss common concerns together. The remainder of the Workshop was devot- to involve PSMs throughout this process.
ed to three interactive activities. Attendees To provide further feedback, to acquire
identified the top twenty issues facing more information about the DoD PSP
Workshop Open Forum Top Issues PSMs and the overall Patient Safety Pro- Workshop, or to request copies of medica-
gram in a dynamic, brainstorming “Open tion reconciliation forms, please contact
1. Leadership Forum” session facilitated by Drs. Marks Erin Lawler (;
Disconnect and Rake. PSMs prioritized their leading (301) 295-8125).
Education concerns as follows: standardizing
2. Workload National Patient Safety goals, educating
Directive (overload) and connecting with leadership, IT, com- PATIENT SAFETY
puterized access to TapRoot™/RCA tools,
3. Discontinuity
and timing of feedback.
4. Leadership
Published quarterly by the Department of Defense
Standards: priority and hierarchy
(DoD) Patient Safety Center to highlight the progress
5. Providers (behavior) PA
LtCol Paul Hoerner, Assistant Director, of the DoD Patient Safety Program.
6. Scorecard
PSC, followed with an interactive discus-
sion of the medication reconciliation DoD Patient Safety Program
7. IT
process. Break-out groups allowed atten- Office of the Assistant Secretary
8. Reality, Resources
dees to share best practices, discuss success- of Defense (Health Affairs)
9. Sustainability (multiple)
es and work through common challenges.
TRICARE Management Activity
10. Timing Skyline 5, Suite 810, 5111 Leesburg Pike
Falls Church, Virginia 22041
Feedback and to whom 703-681-0064
The small group, interactive theme con-
11. Ownership Forward comments and suggestions to:
tinued with three end-of-the day focus DoD Patient Safety Center
12. Consistency of purpose groups highlighting education and train- Armed Forces Institute of Pathology
1335 East West Highway, Suite 6-100
Same page ing (CERPS); team coordination (Team- Silver Spring, Maryland 20910
Standards Phone: 301-295-7242
STEPPS); and using data (PSC). Topics Toll free: 1-800-863-3263
13. Ambulatory discussed in the CERPS focus group DSN: 295-7242 • Fax: 301-295-7217
14. NPSG: standardized approach ranged from identifying the need for Website:
15. In mission/vision cross-service sharing to TapRooT™ com- E-Mail to editor:
16. RCAs-coordinate with other special puter program use and RCA best prac- DIVISION DIRECTOR,
investigations tices. In the Team Coordination group, COL Steve Grimes
NOTEMS template PSMs shared best practices and learned DIRECTOR, PATIENT SAFETY CENTER
Geoffrey Rake, MD
17. Handoff how others implement and maintain DIRECTOR, CENTER FOR EDUCATION
Standardization TeamSTEPPS in their facilities. The Using AND RESEARCH IN PATIENT SAFETY
Eric S. Marks, MD
Common purpose Your Data focus group highlighted issues DIRECTOR, HEALTHCARE TEAM
18. Access to TapRooT™/RCA tools on computer concerning information feedback, COORDINATION PROGRAM
Ms. Heidi King
19. Clarification of data flow inter/intra facility data comparison, and
RCA/SE discussed the need for a list of RCA action ARMY
items and FMEA topics. LTC Robert Durkee
Legal vs. PSM NAVY
Ms. Carmen Birk
20. Sharing experience AIR FORCE
The PSP and the individual Services are Lt Col Kathryn Robinson
responding to the valuable Workshop PATIENT SAFETY PROGRAM NEWSLETTER EDITOR
Phyllis M. Oetgen, JD, MSW
feedback. The Air Force solicited further