The Women's Health Division
Pennsylvania Hospital, Penn Medicine
The interdisciplinary leadership team observed a concerning trend from FY16 through FY18: The number of safety events reports was static, yet more were events were reaching the patient and resulting in harm. A thorough review of all safety events revealed common themes including interprofessional communication, handoff communication, and acuity response. TeamSTEPPS, an evidence-based program to enhance team performance and patient safety, supported the development of a team safety structure.
The team provided interdisciplinary education to more than 450 staff, including nursing, providers, respiratory therapy, and anesthesia. An implementation timeline was designed, and components of the program were rolled out strategically through a variety of methods such as raffles, weekly emails, daily data boards, and staff meetings. Stakeholders designed structures to support safety, including standardized safety briefs, a debrief template, and clear guidelines of events that require debriefing.
To effectively build a safety culture, a focus was placed on enculturation of TeamSTEPPS methods and sustainability using escape room activities to engage the team in a creative way. “Drop the mic with SBAR" and “Close the Loop" rounding used a prize patrol approach to reinforce the TeamSTEPPS processes and recognizes achievements regularly. The TeamSTEPPS Summer Olympics keep the skills and tools top of mind, while infusing a little fun. Communication and transparency remain at the center of the program.
Events reaching a patient with a harm score of E or greater has decreased from 12% of all events before implementation of TeamSTEPPS to a low of 3% of all events post-intervention. Additionally, the number of debriefs following unanticipated events has increased significantly, from 2–4 per quarter prior to TeamSTEPPS to 16–24 in the last three quarters. The implementation of a team safety structure has demonstrated that standardized communication, empowering team members in all roles to speak up for safety, and encouraging near miss identification and reporting has had a positive impact on patient safety and team dynamics throughout the division.